Welcome to Buffalo HealthCast

Sarah Robinson  0:02 
Welcome to Buffalo HealthCast, the official health equity podcast of the University at Buffalo's School of Public Health and Health Professions. My name is Sarah Robinson, your production assistant for this podcast. It's Pride Month, an entire month dedicated to the celebration and commemoration of Lesbian, Gay, Bisexual and Transgender Pride. Pride Month began after the Stonewall Riots, a series of Gay Liberation protests in 1969, and has since spread outside of the United States. This month's episode brings us through the importance of advocacy for the LGBTQ+ community in the healthcare setting and beyond, with Dr. Grant Parrelli, CEO and Founder of Professionally Proud. Be sure to visit the show notes to learn more about Dr. Parelli and the work he's doing in the Buffalo community, as well as to learn about a giveaway Grant is running for Pride Month. We hope you enjoy this special episode of Buffalo HealthCast.

Miranda Bosse  1:01 
Hi, everyone, my name is Miranda Bosse, and I work here at the University at Buffalo's School of Public Health and Health Professions. And I work with our graduate public health programs here. Today, I am here with Dr. Grant Parrelli, who is the CEO and Founder of Professionally Proud. Welcome, Dr. Parrelli.

Dr. Grant Parrelli  1:19 
Thank you so much. I appreciate you guys having me.

Miranda Bosse  1:21 
Yeah, it's great to have you here. So would you mind introducing yourself and telling us a little bit about yourself, being a recent graduate of the Jacobs School and also the founder of your own company?

Dr. Grant Parrelli  1:33 
Yeah, of course. So as you said, my name is Grant Parrelli. I'm originally from Indianapolis, Indiana. And then I lived in the Hudson Valley in New York for a while, that's kind of how I ended up here at Buffalo to go to medical school. I just graduated literally two weeks ago, which is super exciting, but also very strange. And I'm going into emergency medicine, my residency is going to be in Indiana, at Indiana University. And a little bit about my company, I actually started it going into, I think, my third year of medical school. And I had some inspiration, as a patient and as a future physician, regarding wanting increased representation and medicine of LGBTQ+ individuals to create safe spaces. So I had this idea to start an apparel brand that would create that visual cue for patients.

Miranda Bosse  2:34 
That's awesome. Thank you for sharing that, of course, we are going to be talking more about your company, and everything. So you talked a little bit about your experience as a patient and as a provider. So would you mind walking us through the journey of your startup, you know, really how you kind of got it off the ground?

Dr. Grant Parrelli  2:51 
Yeah, of course, I started with an idea back in July of 2021. I wanted a concrete way to showcase someone belonging to or support of the LGBTQ+ community. So I thought it would be a nice idea to fuse the LGBTQ+ acronym with any number of professional designations. So such as myself, I will be using MD in the future. So mine is LGBTQ+ MD. But there are so many different designations in medicine and other professional settings that kind of create this. I thought it was cute for lack of a better term, like fusion of those two things, your identity and your profession. And then we also offer "ally" versions for each of these. That way, if you don't identify, you can still show your support. So I had that idea. I kind of worked through the graphic design part because I'm not much of an artist, but bounced some ideas off a bunch of people, finally settled on something, came up with Professionally Proud as the overarching company, and then slowly chipped away at finding a vendor to make the product and starting my LLC and what that all entailed - a lot of Google searches, reaching out to actually the law school at UB, they were very helpful with a lot of that. And establish that LLC and then finally got some product made and started selling online. And right now it's really just word of mouth and small marketing ploys on Instagram and Tiktok. But it's slowly growing, which is super exciting to see.

Miranda Bosse  4:27 
That's awesome. So how has it been received by your colleagues in medicine and also maybe some patients that you've been working with?

Dr. Grant Parrelli  4:35 
Yeah, it's been resoundingly positive, I would say, a lot of support at the Med School amongst my colleagues in my class and then other classes as well. And then some attending physicians have also been super supportive. And as far as patients go, I think that's where I'm most excited about how it's been perceived. I've had people who outright, immediately when I walk in the room, ask me about it and tell me that they they love it. And that it makes them feel so welcomed. I've had people who don't identify that can kind of take it as a point that I'm pretty open minded walking in the door, and feel much more comfortable conversing with me about whatever the topic may be, because there were obviously some very personal topics that come up in medicine. So that is really the biggest positive feedback that I can draw from that this is a good idea and that it is worth the time and energy because people, the patients are the most important part of this. And if they're receptive to it, then that's amazing.

Miranda Bosse  5:34 
Yeah, that's awesome. Thank you for sharing that. You know, you talked a little bit about your initial goal of creating a safe space in medicine, right, for having these conversations, especially because medicine, there are a lot of different vulnerable conversations that can exist between the patient and the physician. So do you think your goals for the company, have changed over the trajectory of start to where you are now? And how do you kind of see that moving forward?

Dr. Grant Parrelli  6:02 
Yeah, definitely. I think, with anything, any initial idea kind of grows and forms or transforms into many different things as it goes along. I've had a lot of different ideas of what I would like to come from Professionally Proud, including an online directory of LGBTQ+ physicians and their allies, a national one that patients can draw from to make sure that they're going to safe spaces from the jump. And I also have looked into certification platforms, to assure that physicians have access to this education, we're just now kind of turning the page where LGBTQ+ health is being taught to medical students, in the last, I don't know, maybe decade or so, which means that there are hundreds of 1000s of physicians out there that haven't had this education. So I think providing that avenue is something that I would love to look into, and make sure that as many physicians as we can, and other health care professionals are educated in these matters and understand what it's like to be an LGBTQ+ person in the United States.

Miranda Bosse  7:12 
Yeah, that's actually leading right into sort of our next topic here, which is kind of talking about the history, not only of your company and your inspiration, but the historical context of the LGBTQ+ community, and why we're at where we're at today, especially within the United States. So could you provide your perspective on where you think we're at in the US, and also, in terms of like, you were just mentioning medical education and education for health care professionals, kind of where the education has come from and where it's going.

Dr. Grant Parrelli  7:45 
Yeah, I think if you had asked me this question, five or so years ago, I would have had a much more positive response. But I think in the light of some very recent events, we're kind of heading in the opposite direction, which is disappointing, but fuels the fire even more to continue fighting for this community. A lot of the context surrounding the LGBTQ+ community as a whole, you could go back, I mean, we're talking 1000s of years to see where the root of this discomfort that people tend to have is from. And it's grown and morphed in a lot of ways, a lot of negative ways. I think the most recent one that a lot of people can draw from is the AIDS epidemic, and the lack of resources, and time and effort put towards solving that issue, because it affected a particular group of people that were forgotten about or discriminated against in medicine historically. A lot of the more recent changes or progression, I guess, kind of started from that point on. And we had a lot of great progress where it was becoming a little bit more accepted in a general sense, with the same sex marriage being passed back in 2015, I'm pretty sure. And, you know, we were heading, trending in very good direction. And unfortunately, we've taken a step back. I say this all with a caveat that there, throughout this entire time, have been negative aspects as well. I mean, I think the true inspiration behind a lot of this change is the trans community, and they are still to this day, some of the most marginalized individuals in this country, which is horrifying. And as a provider, it's my goal to make sure that they - while I don't want to treat them differently, they need more support than maybe your average patient does. And I think having more physicians recognize that can help us continue to head in that direction where we were heading prior to, I mean, you know, Florida's the big one right now that a lot of people could think about.

Miranda Bosse  9:58 
Yeah, no, I think you bring up a lot of unfortunate but really great points because that is the reality that we're all living in, right. And I think it's incredibly important, especially being a provider, you are working with these people day in and day out. And for so many people, as we had kind of talked about before, people are coming to you, because they don't know who or what to do in terms of their health and their well being. So you are their one source of trust and guidance and everything. And so the fact that you're doing this, and you have these perspectives, and you're looking to create more of a change is really incredible.

Dr. Grant Parrelli  10:00 
Thank you. I'm not the only one. There are many people out there, I promise.

Miranda Bosse  10:43 
So would you mind talking to us a little bit about the specific health needs and concerns that you noticed within the LGBTQ+ community? You just started talking about this, specifically within the trans community, but maybe what you've noticed yourself being a patient. And then also, on the flip side, being a provider.

Dr. Grant Parrelli  11:02 
I think, to start simply, one of the most challenging parts of being part of this community and accessing healthcare is knowing whether or not you're in a safe space, when you go to see a physician or any kind of health care provider. That right off the bat can deter people from seeking out health care, which is a huge problem, because everybody needs or, in a perfect world would have access to and continually follow up with their physician to make sure that they maintain good health. That barrier from the get go is concerning, because it then leads people to be less consistent about going to the doctor, to wait until something major has happened, and they're required, almost forced, to go see a physician. And that can again lead to some difficult situations because they don't have the time to seek out a provider that they can identify with. So that is kind of at the base some of the root of the issue. And then just kind of tying in the historical context. I mean, you have physicians out there that still have biases against these communities. And that is harmful to those particular individuals. That leads to a lot of decreased trust amongst that community in the healthcare setting. And they don't want to rely on those individuals for the most up to date information. I would say, as a patient myself, you know, as a cis, white male, my main issue has been whether or not I'm talking to somebody who I can be open with. So I cannot speak for the community as a whole. But those are just some of the things that I've witnessed as a provider and as a patient. I think the biggest one and the most concerning, from my perspective, right now is the onslaught of attacks on gender affirming care across the country. Obviously, they're mostly in southern states, but it's kind of creeping its way into everywhere. And that's at the forefront of my mind of something that I want to champion against. Because I think that community in particular, the trans community is, again, it's been marginalized, and people refuse to keep their hands off of other people's bodies, which is just horrendous, in my opinion.

Miranda Bosse  13:15 
Yeah, I completely agree. Can you talk a little bit about some of the intersectionalities that you've noticed, not only within the marginalization of the LGBTQ+ community, but also looking at other factors of classism, or racism, or disability or veteran status, you know, other things that kind of play into all of these inequities? Maybe that you've noticed in practice, and your perspective on what is some of the good that's being done to address these issues again, and then what are some of the additional barriers that you've seen?

Dr. Grant Parrelli  13:50 
Yeah, I think anytime you mix in an additional qualifier, if you will, or marginalized community, meaning the intersectionality, where you have more than one of those, for lack of better term, labels, it becomes that much more difficult as a patient. I think recent events, I mean, historically speaking, obviously, as far as gender and race go, there have been many, many examples of how women and people of color and black individuals have been discriminated against in medicine, in a professional setting, any number of things, and you kind of have a reservoir of stress that these people have to deal with on a daily basis that takes a toll. And over time that can result in physical manifestations of issues. And a lot of that pent up stress caused by this intersectionality of being part of multiple groups that are marginalized, leads to poor health outcomes, and makes it that much more difficult to seek out care when it's necessary. And find someone that you identify with, right, if we're talking about the Black population as a whole in America, makes up, I don't know the exact percent, but it is not reflected in the physicians that are currently active in the United States as far as the percentage goes. So that right there is a problem that needs to be fixed, right? There are initiatives being done to try and navigate those situations, to try and create environments that are more friendly and receptive to people of various backgrounds. And we've seen a lot of that change at Jacobs, it was spearheaded by our own Black students at the Jacobs School of Medicine: Dr. Adetayo Oladele-Ajose, Dr. Toyosi Olafuyi, Dr. Dolapo Olawunmi - those are some of the main key players in that. And they've done a lot of great things to create an environment and an anti racism, education. So those are some of the positive things that I've seen that are wonderful. And we're trying to mirror that with the LGBTQ+ education as well. I think a lot of this is happening across the country, too. There are a number of schools that have already implemented a lot of these things, which is wonderful to see. So I'm hoping it just continues because that's what medicine should be about, you know, creating very competent providers across the board.

Miranda Bosse  16:11 
Yeah. I appreciate your perspective on these very broad and hard to answer questions as well, right. Like you said, these are issues that exist not only within Buffalo, across the state, across the country, but across the world. And so how do you grasp and grapple with all these different things as just one individual provider, but I think the work that you're doing, and that some of your colleagues are doing and everything is so important, and even your company, it's really, what I see as maybe, informally is an advocacy company, right? You're bringing awareness, and like you said, you're putting visual representation to the LGBTQ+ community or to ally ship. And so would you mind now kind of diving into that advocacy component that your company is really bringing to creating safe spaces in medicine? How do you think healthcare professionals can ensure that healthcare environments are inclusive and welcoming, and accessible? And even that, we could break down into multiple questions, right?

Dr. Grant Parrelli  17:15 
Yeah, I think, so there are surface ways to make it more well known that you're supportive, right, I think that's kind of the basis of my company is to create that visual cue, right? And there are many other ways, not just my company that does that. But there are many ways that you can do that. And I think, taking the time and effort to make sure that it's well known, and that you really put that out there is very important, right? Because if you have to search for whether or not somebody is LGBTQ+ friendly, and really search for it, then it's kind of like, are you actually, if you're not upfront about it? And you're not very open about it, then it's a little bit questionable. So I think that's a great way to start, I think the main issue is education on these matters. I think the providers, as a provider, you are in a unique situation where you have access to knowledge that the general population does not, or at the very least, your job is to kind of convey that information to the general population, they might have access to it, but they may not understand exactly what they're reading, right. And you have been given the tools to do such a thing. With that said, I think what we mentioned before, there's a lack of education, amongst many providers with LGBTQ+ issues. There are probably many providers out there that don't even know what hormone therapy is, right? Or don't know how to prescribe that or don't know how to - don't put the effort in to figure that out. That is the root of the problem - that people, their biases affect what they choose to educate themselves on. And as well as just historically in medical education, where those areas have been lacking. So I think those are probably the two biggest components, I would say. And again, we're trending in the right direction from a medical education standpoint, and I can only hope that it continues.

Miranda Bosse  19:05 
Yeah, absolutely. So obviously, education is a huge proponent of moving these efforts forward and everything, but also dismantling a lot of the stigma and like you said, the biases that exist within healthcare and just around the LGBTQ+ community. So do you think that there are enough resources or support services for the queer community in healthcare? And would you mind addressing this from both the patient and provider perspective?

Dr. Grant Parrelli  19:37 
Right off the bat, no, is probably my response to that. I think, where there are a good amount of resources, I don't even know if it's necessarily the correct amount of resources, are going to be the major cities, right - New York City, San Francisco, some of those more overtly known gay friendly or LGBTQ+ friendly environments, where they do invest a lot of their time. and energy into those issues. From my research, it's more places like Buffalo that have a decent population, kind of mid-sized to small city that don't have as much money or resources going towards these issues. But there are still plenty of the population that identify, right? I think that comes with, again, there's not as many people, there's not as many resources at the base, right? So how do you spread these out evenly? I'm not going to pretend to know how to do that. But I think that's really where the issue is, not in those big cities as much as it is in some of the smaller areas. I would also say, as a provider, kind of what we've been touching on, that lack of education in medical education is a great place to start. I think there was a study done in 2011, that showed a very small percentage of schools had more than five hours of LGBTQ+ education amongst the four years of medical school, which is a very small amount, and there was a subset that had no education whatsoever. And unfortunately, that study is a little old, kind of outdated. So hopefully, it's changed since then. But you know, in 10 years, only so much can change. So there's still a lot of room for growth in that regard. And I think the change unfortunately, is going to have to happen with the students. That's kind of what I've noticed over time, while the administration has been very receptive and very helpful in getting things off the ground, the passion, and the knowledge is coming from the younger generations, right. And until that kind of flips, where we're the ones that are in charge, that's kind of where it has to come from, unfortunately. I mean, there are many great advocates in older generations, I recognize that and appreciate the support, but just from my personal experience, that's what I've seen. So I think continuing to support and show students that they have resources and means to make these things happen is very important. And we'll start kind of championing that change.

Miranda Bosse  22:10 
Yeah, I think you bring up a great point, though, in terms of education, right? You know, we could talk about this all day about things that need to be done in the educational system as a whole, but also in things, making LGBTQ+ education a part of the medical system, and healthcare professionals, systems and everything. But also education doesn't just stop once your degree is done, right. And so I think what's really important is that your company is doing this the way, at least, we've seen it, is that your company is doing this continuing ed in an informal way, creating advocacy, while you're still continuing to practice, not just while you're in med school, which I think is so important, right? Because as you know, as a student, for many years yourself, it doesn't just end right when you get that degree. And so carrying that into the workplace, and then carrying that beyond your initial starting point. So now speaking to your personal perspective on your own company, why do you think initiatives are so important to the LGBTQ+ community, such as your company, what has this really meant to you, not only for being an entrepreneur and creating this whole, this journey and everything, but really at a broader scale for the LGBTQ+ community?

Dr. Grant Parrelli  23:29 
Yeah, I think one of the main things that I have appreciated about this experience is, and you'll hear this a lot from older generations, when they see TV shows or movies that that they wish had been around when they were younger. This is something that I wish I had seen when I was going through my experiences as a young, queer person. It took me quite a while to come out and feel comfortable with that, as it does have many individuals in the community. And so that kind of continues to fuel the fire. And I think what it does is shows that there are people out there that care that want to be there for you, and that want to change the way that this community is perceived as a whole. And that's like, one of the most important things I think from a patient side is just knowing that somebody does care, or finding someone that you can identify with and understands whatever it is that you're going through. Professionally proud is wonderful, and I'm so proud of myself for having started it but it is not the end all be all by any means. I think there's so much more that can be done, especially with people that have more resources than myself and I'm balling on a budget like we do, but we're trying our best. So I think continuing to make yourself known to not shy away from maybe some larger individuals or groups that don't want us around and can Anything that fight regardless of other people's perspectives or biases is super important. And then just kind of getting that ball rolling. I mean, it's already been rolling, right? I'm not I'm not the start of this by any means, but I hope to continue to roll it in the right direction, even as we're combating some, some difficult climates.

Miranda Bosse  25:19 
Yeah, like you said, the work never stops. And I think that's just another point that your company just pushes to that it really does never stop. In your experience, you know, you talk about reaching audiences that maybe yourself as a kid, or as a young adult didn't have, people who were able to advocate for you, or you just didn't even have that representation. And maybe that was because, well, one, people didn't really talk about these things. But two, things were not out on the internet or social media as much before. And now, as we all know, through your Instagram and Tiktok presence you've really been able to reach so many more people through that audience. And I think there's a lot of good that can come from social media and reaching such expansive audiences. So can you talk a little bit about your business's journey on social media? And how you see that those platforms as serving as advocacy units for your company?

Dr. Grant Parrelli  26:20 
Yeah, of course, I think one of the main things that I've learned as a small business owner is, you are limited in your resources in terms of marketing and advertising, right. It's expensive if you go the more traditional routes, but using something like social media is free. It takes a lot of time, energy in terms of that currency. But as far as you know, financially, it's free. So it's a great way to try and connect and get your name or brand or idea out there and kind of get a following gauge whether or not people are interested. I am a millennial. And I recognize that there are many Gen Zers that are much more adept and quicker at the social media game. And I just try and hang on and work on whatever trends I can to get noticed. And get people engaged and excited about LGBTQ+ education and representation. I think humor is always a great thing to go off of that is something that I've done my whole life. And as I've learned in medicine is a mature defense mechanism. It's a slightly healthier way to kind of work around some of the more touchy subjects, I would say too it allows, like, you're saying the younger generations are far more engaged in those platforms. And that's one of the main inspirations behind my company is to make sure that people in those vulnerable ages know that there's support out there, and there are people advocating for them in these spaces. So getting in touch with those younger individuals, however it may be, it's super important. And I'd say I've had the most fun and most feedback from Tik Tok for sure. And I think it's a great platform. It allows you to educate in small, digestible pieces. And I think that's a huge part of it is mixing in some humor, but then also trying to be like, Hey, here's like, just a general piece of information of how you can navigate X Y & Z situation, right. So I'm hoping to kind of take that to the next level and continue to grow. And use those platforms as a positive reinforcement for what professional crowd is trying to do as a whole.

Miranda Bosse  28:41 
Yeah, I love that. And I think you've really, you know, hit the nail on the head with reaching younger audiences not only standing up for them, like you said, and letting them know that, hey, there's people in this space who are advocating for you and are doing the work, but also meeting them where they're at, which is usually through small bits of information on social media and with humor. And like you said, that those training, audios and everything, so I think that's really awesome, that blend of information that you've been able to showcase. My next question is how do you really like to stay informed and up to date on emerging issues and trends, not only in healthcare in general, but LGBTQ+ specific health care issues?

Dr. Grant Parrelli  29:23 
I would say the main source of my education in those regards, is, I guess there's a few avenues, news outlets, although they tend to be quite pessimistic, and can be a little overwhelming at times. I think it's so important to tap into those when you have the space and the bandwidth. I would say also just chatting with other people that identify in the community and hearing their perspectives and what they know and what they've heard, is a huge, huge part of it. I think that is, you know, we call ourselves the LGBTQ+ community and I think that's a huge part of how we can be successful and advocate for ourselves as if we kind of lean on each other. And grow in that way becomes a lot more powerful. So that's something that I've tried to really take advantage of. And then, honestly, social media, I learned a lot from any number of those platforms about changes that are going on, people share a lot of great links to some of the legal proceedings that are occurring in different different areas. On Twitter, there's a lot I follow a lot of doctors that will tweet, you know, new studies or new findings that are really interesting and kind of keep me up to date on that. And so those are probably the main avenues, I would say.

Miranda Bosse  30:40 
Great. Yeah. So you talk about, you know, obviously, we refer to the LGBTQ+community as a community, as it very much so is, and I think the healthcare community is also  a community in itself, right. So have you had any partnerships or collaborations or connections with any community organizations in terms of the health equity work that you're doing with your company in expanding your own community resources?

Dr. Grant Parrelli  31:09 
I have had a couple of partnerships. I recently partnered with Excelsior, orthopaedics and the Buffalo surgery center to sell branded attire to their employees, they were very receptive to the idea from the start when I initially launched my products. And we've kind of been working for the last seven or eight months to try and get it off the ground. And I'm super excited, because here in Western New York, they're a pretty big entity. And so just knowing that there are going to be safe spaces created with that little visual cue is amazing. And to have a company like that, that wants to do that, and put the effort, kind of put the money where their mouth is, is amazing, right? So I think I'm hoping to continue to grow in that way. And then as a result, once I am able to profit, begin reinvesting this and to other community organizations that could benefit from more funding. And that's kind of my big goal right now. Because I can't do it all. I don't want to recreate the wheel either. But I want to be able to support some of those more well established groups and whatever way I can. So that's kind of what I'm hoping for. I have a couple other partnerships in the work. And it works, I would love to kind of look into some more advocacy groups, like you were mentioning and local, like the Pride Center, and things like that, to see if there's any way that I can help or that they can help me. So that's kind of like a next step direction for sure. So stay tuned.

Miranda Bosse  32:50 
Yeah, that's awesome, and congratulations on the partnerships you've had already. That's really awesome.

Dr. Grant Parrelli  32:55 
Yeah, it's exciting.

Miranda Bosse  32:56 
Yeah. So now into, you know, the fun part, you know, so we've been talking about what your company does and everything, but we haven't talked about your merch. So I gotta know, what do you have, walk me through your website, what is customizable about it, and everything. And so what can somebody get for their practice or for themselves?

Dr. Grant Parrelli  33:19 
Yeah, so we offer a number of apparel items right now. So we have t shirts, crewnecks, zip ups, hats, there's a bunch of stuff. And we're always kind of adding things here and there, as I continue to grow and I'm able to reinvest in the company, the logos themselves, so that fusion of the acronym with any number of professional designations, totally customizable, so I have created a number of things that I never thought of before. That's the beauty of customization. There are so many people out there that have different things that they are a part of, and they want to have this representation. So essentially, you can go to professionallyproud.com. And any of our items, you can get customized with whatever logo you're looking for. So when you add the item to your cart, you can type in whatever logo you want. And then I send that out to get made and then I can print it on any number of items. And then we also offer some different bag options. We have tote bags, and we have fanny packs, which are very in right now coming back from the 90s which is awesome, and especially in healthcare, I love it because I can put my stethoscope in there, I can put my phone in there and walk around and I'm kind of you know, unencumbered by a lot of the wind. You're at the go ready to go. And so those are kind of the, you know, the options that I have right now. And as I said, we're always growing and looking for more things and partnerships with different companies that are interested.

Miranda Bosse  34:50 
That's awesome. Well, we have to check out your website, you know, go to professionallyproud.com, correct?

Dr. Grant Parrelli  34:56 
Yes. Yep.

Miranda Bosse  34:57 
All right. So what are the next steps for you? On top of, you just graduated from med school and you're running a business and you obviously have so much free time and I'm sure you're just sitting around. So what are the next steps for you?

Dr. Grant Parrelli  35:12 
Yeah, well, I will be moving to Indianapolis. About mid-June, my partner and I are heading over there. And we'll kind of start our new adventure out there. And residency starts at the end of June, like June 22nd. So it's kind of an ease into it, it's just like an orientation to start some some shifts here and there to get your bearings, and then kind of go from there. As far as the business goes, I mean, I take it with me, I'm going to continue to grow it the best way that I can. As we continue to grow, because we've definitely grown a little bit more the last couple of months, I'm going to be looking to you know, bring some people on. I'll probably start with friends and family, which I know is a little questionable business but when you don't have much to go at, you kind of have to work with the resources you do have. So we'll start there and then I'd love to tap into you know, medical students that would like a part time gig or something like that. That would be that'd be super cool once I have the resources. So we're definitely not going to stop, I know things are gonna get busy. As my partner said when I when I initially told him that I was going to start a business while I was in medical school he's like you're absolutely insane what free time will you be doing this? And you know what?

Miranda Bosse  36:30 
You did it anyway.

Dr. Grant Parrelli  36:31 
Yeah. Figured it out. I think as long as the passion is there, as they say, if there's a will there's a way. So yeah, I'm definitely not going anywhere. Things might morph for the future, but I'm excited to see where we go.

Miranda Bosse  36:46 
Yeah. Well, Grant, it has been so great talking to you today. Thank you so much for sharing all the information about not only yourself but your company. And we really wish you the best of luck and we can't wait to see where Professionally Proud goes and you yourself as a physician. Thank you so much.

Dr. Grant Parrelli  37:03 
Thank you guys so much. I really appreciate it.

Sarah Robinson  37:09 
This has been another episode of Buffalo HealthCast. Thank you to our amazing guest, Dr. Grant Parrelli for joining us today. Be sure to visit the show notes to learn more about Grant and the work he does in our community. This episode was written and recorded by Miranda Bosse and Sarah Robinson. Our theme music was written and recorded by Dr. Sungmin Shin of the UB Music Department. Our production assistant and sound editor is Sarah Robinson. Buffalo HealthCast is produced by the University of Buffalo School of Public Health and Health Professions. To learn more about health equity in Buffalo, the US, and around the globe, visit our website linked in the show notes to find more episodes. Thank you for listening to another episode of Buffalo HealthCast.

Intro  0:01 
Welcome to Buffalo HealthCast, the official health equity podcast of the University at Buffalo's School of Public Health and Health Professions. In this podcast, we cover topics related to health equity in Buffalo, the US, and globally. This season, we'll take a look at food insecurity and health equity on a global scale. You'll hear from experts around the world who specialize in areas like urban agriculture and food contamination, soil science, food sovereignty, refugee health, intensive agriculture, and more. This season's episodes were completed in Dr. Kasia Kordas' Global Health class, a graduate level course offered at the University of Buffalo, and produced by the School of Public Health and Health Professions.

Elisabeth Stowell  0:55 
Hi, I'm Elizabeth Stowell, and I'm a grad student at the University of Buffalo in the Environmental and Water Resources master's program.

Veronika Semenova  1:02 
And my name is Veronica. I'm also a graduate student in the Microbiology and Immunology Department.

Elisabeth Stowell  1:09 
In this podcast, we are looking to explore the relationships between food systems, food sovereignty and refugee health and how they're all intertwined. The International Food Policy Research Institute has a strong and complete definition for food systems. Food Systems are the sum of actors and interactions along the food chain value from input supply and production of crops, livestock, fish, and other agricultural commodities, to transportation, processing, retailing, wholesaling, and preparation of foods, to consumption, and disposal. Food systems encapsulate everything it takes to produce, distribute, consume and dispose of food.  The United States Food Sovereignty Alliance provides a definition straight from their global forum defining food sovereignty as the right of peoples to healthy and culturally appropriate food produced through ecologically sound and sustainable methods, and their right to define their own food and agricultural systems. Within this definition, is a statement that people have a right to control the food systems, that the food they consume is a product of.

Veronika Semenova  2:20 
When people are displaced, and need to seek refuge in new communities, they often become more vulnerable with inadequate or inequitable access to services and resources that they need to keep up their health and well being. Refugees have the basic human right to health and access to equality and culturally appropriate health services. This means refugees have a right to food sovereignty in their communities of refuge, the right to control and define their food systems to obtain healthy and culturally appropriate food wherever they are.

Elisabeth Stowell  2:57 
According to the World Health Organization, today there are over 26 million refugees globally. The good health and wellbeing of refugees is essential. Due to the circumstances that made refugees leave their home, they often are more vulnerable to diseases, injuries, and health complications along their journeys and upon arrival to a new place.

Veronika Semenova  3:20 
One of the most important aspects to promoting and developing refugee health is to establish food systems that allow refugees to achieve food sovereignty. There are current efforts being made in the Western New York community, but there's still progress to be made to attain health equity for refugees. Providence Farm Collective out of Orchard Park, New York is a nonprofit organization working with people from Liberian, Ethiopian, and Somali Bantu communities to name a few.

Elisabeth Stowell  3:51 
Today we will be speaking with two guests who have experience and expertise in this topic. Dao Kamara is the Community Engagement Coordinator at Providence Farm Collective, a farmer and owner of Grow Your Own, and a community leader for the Liberian Farm Project.

Veronika Semenova  4:08 
And Alex Judelsohn is a doctoral student in Urban and Regional Planning at the University of Michigan. Broadly, her research interests include how the built environment impacts health, particularly for immigrants and refugee populations. Her dissertation research looks at the role of refugee-run organizations and resettlement in two major resettlement counties: Kent County, Michigan and Erie County, New York. Prior to her doctoral education, Alex earned a master's in Urban and Regional Planning from the University at Buffalo. She worked as a research associate at the Food Systems Planning and Healthy Communities Lab at the University at Buffalo, where she collaborated with colleagues across disciplines through the Community for Global Health Equity. She has conducted research in the United States and Kashmir.

Elisabeth Stowell  5:04 
So we're just going to jump into some questions with Alex and Dao. So first off, it's important for us to hear a little bit about your story with food systems and refugee health. How did you become interested in it? What started your journey working at your organization or in the research that you do?

Dao Kamara  5:22 
Again, I'm Dao Kamara from West Africa, specifically Liberia. I was born as a farmer, grew up as a farmer, and went to school as a farmer. But after the Civil War, in my country, Liberia, I fled my country, then went to the neighboring country, Côte d'Ivoire, where I spent 2 years in a refugee camp. But for the past 2 years in a refugee camp, I lived on handout, because I don't have access to my tradition, or access to my culture, and no access to the culturally relevant food I used to eat. Because being a refugee, I have no access to land, to grow what I need to grow. So when I was selected to come to the United States, I just don't think I was ever going to have access again to my own food and to my own culture. So coming to the United States, I was told I'm going to live the American dream, in which it was true, to take care of my family, send my kids to school, which was successful. But something was still missing because my way of life was still missing. And I don't know how to better be connected to that life. I can only be connected to it through land, and I can have access to the food I used to grow. So my journey to Providence Farm Collective. It was just last year when I started working with Providence Farm Collective. But before working with Providence Farm Collective, our farm with Providence Farm Collective, the first year in East Aurora at the time, Providence Farm Collective was actually leasing our land. And then the year we farmed with them, we were not successful, because the land was not a prime soil. And it was just a horse pasture that we were actually farming on. That year, we grew 3000 pounds of food. And it was actually disappointing. And we had to speak to Kristen, the executive director, to let her know, look, you can find a better land for refugees because we drowned between our jobs and taking care of our family, just for us to be able to grow food. And now we can put in so many hours and take your rigs and we can have a real good produce. It was not looking good. So Kris and her team put together - they were able to farm the land that we're on today called Burton Road. So on Burton Road last year, we farmed, we grew 91,000 pounds of food. So you can see the difference between the 3000 and then 91,000, and today at Burton Road, we have 8 different communities, 275 farmers that grew over 20 different crops that are very culturally relevant to society. So today we have access to our cultural food, we have access our own farmers market, we have access to actually delivering food into food pantry, and we are then now be able to address the food insecurity in the food desert area so that everyone can have access to actually cultural, fresh and relevant food in the region. I think that's my journey to PFC.

Elisabeth Stowell  8:17 
Thank you for that.

Alexandra Judelsohn  8:18 
Thank you, that was really interesting to hear. I'm Alex Judelsohn. I am a researcher. I am from Buffalo. I'm currently pursuing my PhD in urban and regional planning at the University of Michigan. And kind of, I guess my story of how I got to studying this topic, which I guess first off, I'm broadly interested in how policy processes facilitate or hinder equitable and healthy communities. And I think of policy really broadly, you know, not just written laws, but processes, procedures, just guidelines that govern people. And I hope, you know, at the national and community level, I can conduct applied research that really pushes governments to think about who's doing the work in refugee resettlement and organizations assisting people. So I guess about 10 years ago, I came back to Buffalo. And I was working at Grassroots Gardens in Western New York, which is an amazing nonprofit that helps people that want to start community gardens in their neighborhoods, and a lot of the community gardens were on city owned land at that time. I'm not sure what the number is now, but I think at that time, about 15% of land in Buffalo was vacant, and I kind of learned about the growing farmer refugee population while I was in this role that I decided you know, I might want to work at a nonprofit, but thought that I maybe needed to further my education and I met Dr. Samina Raja, who is the director of the Food Systems Planning and Healthy Communities Lab in the Department of Urban and Regional Planning at the University at Buffalo. So it was seeking out research opportunities there and saw through work with community partners that there was little research about how former refugees in the US navigate new environments when someone is in this new home, you know, like Dao said, how do you find culturally preferred foods? Are those vegetables grown here? So we got some funding to conduct a pilot project to explore specifically how people from Burma experienced new food environments and the ways in which local governments supported or hindered their access to culturally preferred foods. And this was an amazing experiences for me, you know, I never really thought about the world of research, I got to work with faculty from urban planning, public health, social work, and medicine. And we had a community advisory group with leaders from the refugee community and organizations that serve refugee clients. And this kind of planted the seed for going further with a research career and that I decided that I wanted to just pursue a PhD. But it was interesting, in that research, people when we asked about food, they kind of looked at us like, why are you asking this question - of more pressing concern or issues like housing, transportation or safety. So this kind of guided, you know, my current work, which looks at the role of local government in resettlement since, while people can move when they arrive in the US as refugees, unlike, people that come under other types of Immigrant Visas, people that arrive as refugees are placed in a specific city. So I can talk about my research more later. But that's kind of how I got to where I am today. But I guess also, in addition to my role as a PhD student, I work as the program manager for the Community for Global Health Equity at the University at Buffalo, which is a research center, and we have a lot of faculty affiliates, and I just want to plug, we have a refugee health and well being -they're called Big Idea Teams, and the two faculty that lead that Melinda Lemke, who's in education and Kafuli Agbemenu, who's in nursing, do amazing work, and I highly recommend looking up their work, and they work directly with different refugee communities.

Elisabeth Stowell  11:55 
Thank you very much. It sounds like we have two guests that have a great background in this topic, and we're gonna get a very broad and rounded view of health and food systems.

Veronika Semenova  12:06 
Thank you for sharing your stories. Our next question is what food systems and food sovereignty really mean?

Dao Kamara  12:14 
For me, as a refugee, and from a cultural background of food, where I came from, food is medicine, we just not eat because we want to eat but we eat because the food has an impact that it makes in our life, in our health. Most of the food that we eat is actually sicknesses like high blood pressure, diabetes, high cholesterol, treat your bowel. And for so many reasons that we eat what we eat, we just not eat because we want to eat. So if we become we become  refugees, and we don't have access to this food, what happened to us, our health began to decline. So we followed up most of our errors that we brought into this country as refugees and immigrants their health was declining, they were dying, and they couldn't even be able to survive in such an environment where they couldn't find the culturally relevant food that they used to eat. So food was not just something that we can just eat anything. But it's considered to be medicine, and the sovereignty part of food, food has power, because there will be power because the entire world, the only thing they have in common is food. People may not like politics, they may not even like some other social gallery, they may not like this, but there will be no way that we all will be able to ask anything when it comes to food. So food is sovereignty, food is power, with food, food with food, we all can come together and discuss how can we address the food insecurity? How can we address the food desert? How can we address the cultural and relevant food that should be in places than going to a food pantry, you will find canned food, would have found food that is that they consider to be food that they are going to give out to refugees or giving out to immigrant, giving out to the neighborhood but this food is not healthy to human body. So food is something we should consider because it is medicine. It has power to bring people together, and how to address the insecurity of food within our region.

Elisabeth Stowell  14:16 
Thank you, Dao, I think you've just given us the perfect example and reason of why so many global health experts and researchers should really care about food and the food that's available to refugees and having land access for them to be able to grow their own food. Thank you.

Alexandra Judelsohn  14:31 
Yeah, I don't have much to add. But you know, like Dao said, food is power, everyone has to eat. It's one thing that we all have in common. And I think, you know, in terms of the food system, we often think about this, you know, envision kind of that circular image of the value chain of what goes into growing food, producing food, transportation, sale, and then consumption and the waste, but also like what about the policy environment, and also the cultural norms that are embedded in food, which can, you know, hinder or enable access. I think about the WIC program, Women, Infants, and Children, where a lot of the food is not food that people from other cultures necessarily want to eat like peanut butter. So food sovereignty involves, you know, making sure that food is culturally preferred and appropriate for people. And that those who produce and consume food are centered in this dialogue, and not corporations and people marketing food.

Elisabeth Stowell  15:38 
Yeah, so I like that you pointed out that it should not be all about corporations and people marketing food. Next, we want to talk a little bit about the work that you currently do. So Dao, I was wondering if you could tell us about the work, maybe some specific projects or what you specifically do on the farm?

Dao Kamara  15:53 
Currently, I'm the Community Engagement Coordinator of Providence Farm Collective, and I'm involved in so many projects. Really, one of my goals is to actually work with the refugees and farmers, immigrants, even blogs and look for us to make sure that they can have resources to be successful in farming. Farming is hard. If you're doing farming, you actually need the support, you need the resources to actually do the work. And most of the refugees and immigrants that we find in the farming field, they may not be educated, they don't have English as their first language. And for them to survive in the farming world, they will need the resources for them to supply. They will need to get the understanding because if you find a landscape in the United States, and from where they come from, there's two different grain seasons. You come from the climate that is very hot and you are coming to the climate that is very cool. And there's some other food or actually some other crop that actually doesn't grow in the cool, in the cool weather it's very sensitive to weather. And for them to be successful, they need the kind of education that you have to give them. The resources so they can be they can be successful in the different seasons when it comes to where they find themselves. So being a community engagement coordinator, I work with a farm director and a farm mentor to provide the resources to those farmers who are actually engaged into producing the food that actually we all need to eat. Again, I'm already engaged with children, because children are the future. We are in the process where people are aging out and we need new farmers. Now, getting getting new farmers we need a new generation. And farming is a culture - it needs to be passed down from one generation to another generation. So you find there's a disconnection between families, disconnection between generations, the new generation we have today, they really don't know nothing about farming, they really don't have an idea of farming because all they know to farm it means you have to play with the dirt. But it shouldn't be that way. Farming is not just playing with the dirt. You can find a researcher in farming, you can find different careers in farming, what you can do and be part of the family work. So we try to build out this, we try to build a connection between families. So I work with 51 kids, this summer program, and those kids were working alongside their parents. So kids that were actually disconnected to the parents coming on the farm working, they were able to build a connection, they were able to actually understand the culture, understand the value of food that their parents are telling them. This is what I used to live, this is what I used to eat, this is what I used to live in. But just saying it and not just seeing it was a two different thing. So this year, because of the summer program, we found our kids are connected to the food, they're connected to agriculture, and they're also connected to their parents and to their culture, to their communities, to their neighborhood as well. Then I'm working on another program called the Food Aggregation Program. This is where we got funding from Buffalo Bills Foundation. And then we'll pay a fair price to our farmers. Because farming is so hard that you can't just purchase for less. As we can based on the kind of crops and food our people grow. So the money we get from Buffalo Bills Foundation, we were able to buy to buy the food from from our farmers. And then we take the food and put it into the food desert we put it away into into into the food pantry we work with Massachusetts project. So we work with all of them the center so that we were able to place a real fresh food culture relevant  within the food pantry that the community can access, not just community alone, but the entire the entire region that actually have no food so that in Buffalo, they will be able to access fresh food, not just canned food, and it was very successful. We had our own Farmers Market on Grand Street that will run from 10am to 1pm. And the Farmers Market served over 700 people this year and it was just different, different different backgrounds of people that came. It was not just only the refugee community, not just only the American not just only the American community. It was a diverse community, that came to there and said look and came to buy the food and came to actually experience it. And one thing we added is the recipe, because most of the crowd that we had gripped we're reading on the web. Now we are working on creating recipes so that if you buy the crops, you will be able to know how to prepare it. You'll be able to know how to take your crops home so you can have interest in what you are buying, not just taking something home that you don't really know. So being a community engagement coordinator, I have to connect all the dots, make sure what we're Providence Farm Collective to measure to, to kind of actually explain to our farmers the policy, the guideline and be able to turn it the mission and vision of Providence farm Collective. Also serve as an ambassador to get out there to be able to check what PFC is all about we are not just another group of people, we are part of the community  we are here to share. We are here to invest, we are here to contribute to society. So whatever community we find ourselves in, we are part of the community and we should be as such. That's my role.

Elisabeth Stowell  21:04 
Thank you so much, Dao. It sounds like you're doing some amazing work there and really getting out into the community and making the important connections that you need to succeed and to see all the people that you work with succeed. Alex, I wanted to ask because Kristen and Dao mentioned that they maybe previously knew you. Have you worked with Providence Farm Collective or Dao before?

Alexandra Judelsohn  21:26 
Yeah, well, I had the opportunity to speak with Dao in relation to my dissertation research. And then, through my role at the Community for Global Health Equity at UB, I helped to organize the annual western New York New American and Refugee Health Summit. So this year was the eighth annual. I was involved years ago when I was a graduate student at UB and then the seventh and eighth annual one I got to help plan in my role and Dao spoke on a panel there this year. And PFC was tabling at the event. So it was great to collaborate on that event. And I think it's a pretty unique event to our region. I've heard some people from Rochester really excited about it, I would love to expand it in the future and make it bigger.

Elisabeth Stowell  22:20 
Awesome. That's cool to have two guests that have already been connected through this community in this topic.

Veronika Semenova  22:26 
Can you please speak to us a little bit about your own research on food insecurity and refugee health? Are you doing any current or recent research? And what are the results telling you so far?

Alexandra Judelsohn  22:40 
Yeah, sure, I can speak a bit to a project I worked on. This is probably from about 2016 to 2018. And we call the DDFAAR - Dealing with Disparities and Food Access Among Refugees. So at the time, there was pretty limited literature on the topic, and it was mostly from public health, nutrition and anthropology. And scholars kind of found that former refugees find it difficult to maintain nutritious diets in their new home country and their resettlement country. And while people might continue to eat more whole healthy foods that they ate prior to arrival in the US, acculturation, especially with younger generations might impact food norms mimicking US foreign populations. And you know, for example, I think one study found that amount of packaged foods and snacks was higher among Somali mothers than the native born populations. But the issues with a lot of these studies is that they largely emphasize the role of the individual, they don't really consider the structures or the systems at play. And obviously, food access is not completely dependent on individual choice. That's a small facet of it. Where do people live? Can they drive to a supermarket? You know, not that supermarkets are the only places to shop. But are small grocery stores in their neighborhood either available? Are they more expensive? Do they accept SNAP or WIC? So these studies didn't really explore how planning and policy kind of mediate the experience of accessing food. And we kind of found that people you know, I would say, like, our main findings were that people, you know, people definitely were kind of surprised when we asked about food, like I said earlier, other issues like housing and transportation and employment seem to be more pressing. I think also, I learned a lot in how important language was, so like I mentioned earlier, we had a community advisory group, but some things just didn't translate well. Like one question in particular was, do you still think about like, do you eat processed foods, but in my mind, processed foods are the foods that are in packages in the middle of the grocery store, but the people we were interviewing thought of processed foods as something like a prepared meal that maybe you would go out to eat, so there was definitely something that were disjointed, that people basically said that they had access to culturally preferred foods. But there were definitely some issues of access in terms of, or yeah, access in terms of land was a big one. A lot of people wanting to grow food but didn't know 1) if they were renters, if their landlords would allow it. And then there was the missing piece of kind of lead issues and safety of growing in the city. And it just really showed that kind of local government was pretty disjointed from the needs of this community. And that, you know, the city might create food inequities. So my current research isn't on food sovereignty and resettled refugee populations that have kind of broadened it. But I hope to go back to this area of research someday.

Veronika Semenova  25:51 
Thank you for your insight, and thank you for expanding this specific field of research.

Elisabeth Stowell  25:56 
So maybe you can both talk a little bit about the scenario of food systems and food sovereignty that you see in Buffalo now, or in Erie County, and maybe how it compares to, like places you've researched, or been, if there's similarities or differences between the conditions of food sovereignty for refugees in Buffalo, or in other places.

Dao Kamara  26:20 
So it's like you know, I've been, I've been in Buffalo, but for the past year, so for us to actually get what we need, we actually used to order food we used to kind of order food from our culture from Philadelphia, from Minnesota, from Iowa, Des Moines that's where we found some of the crops that were actually really needed, were kind of very difficult for us to find that kind of food, in Buffalo. Even if we could find that food in Buffalo, we could sometimes find it in the Chinese store, if we find it, it is very costly, it costs a lot. And because it costs a lot, we cannot afford to buy the food to be able to to feed our families. So people just stay away from it. But as now we have access to learn, to PFC, we got 8 different communities that got grant funded who are now becoming available to the community in our region. And because of the difficulty of getting food, again, I'm gonna say because of the difficulty of getting food here in Buffalo, is actually brought a decline in the health of our elders. Because most of our elders take food as medicine, they just not go to hospital very often, and reason they don't go to hospitals because of because of their health because of the food they eat. But then there's another barrier called the language barrier. Because many people thought that because we say language barrier. So everyone had a specific language, there are certain language that is not written that people really don't speak, we call it dialects. And because of those dialects, and people don't understand it, it's not part of the written language. doesn't have interpreters. So people really don't go to hospital they stay away from them, because people don't understand them. Again, there was the community organization have come into place because refugee agency might help us for three months then after three months. How do we - how do any committees do as an unfamiliar system that really they don't know about and that's when the community organization come into place. So having community organization is actually applause to all that gave us power that we can be able to organize to help our people access their own food system, give them information where to farm fresh and culturally relevant food, how can they be successful in the Department of Social Services going to hospital? How can we how can we be able to provide them an interpreter both in language and in that dialect? And so on this lot, there's a lot of love when they come they come to us with our community and our environment? So there was a big difference between food in Buffalo and there's no food and now we try to work on that to see how we can close the gap.

Elisabeth Stowell  29:00 
Thank you for that answer. Alex, have you seen or done research in any other areas outside of Buffalo that have differed from what you see in Buffalo? Are there similarities?

Alexandra Judelsohn  29:12 
First, I would say that I do think in Buffalo, while maybe policy hasn't moved as quickly as I think it should have, there are amazing organizations.  PFC, obviously, but, you know, PUSH runs some gardens. I think they're on the west side of Buffalo where people can rent plots, Grassroots Gardens of Western New York does amazing work and also Massachusetts Avenue Project. And we do have a Food Policy Council at the Erie County level. And there is a food systems plant for the region called Growing Together. So I think, you know, those are all things that are kind of ahead of other areas. I haven't done in depth research in other locations, specifically on food. For my dissertation, I'm looking at Erie County in New York, and also Kent County, Michigan, which is where Grand Rapids is, and just anecdotally, it doesn't seem like they have anywhere near the kind of food infrastructure, especially for refugee populations, like there's nothing like PFC there. But after the project I talked about earlier, we kind of, we wrote a paper and we looked at comprehensive plans, which for non-planning folks, comprehensive plans are kind of a long range vision for our community. In a lot of places, they're mandated to be written, but sometimes it's voluntarily. And, you know, you hope that is kind of the intention is that it's kind of the hope for the future of a place, but also whose voice is included in the comprehensive plans. So we looked at 10, comprehensive plans. And then if the city had a food systems plan, we looked at that, or maybe some type of health plan, and found that, you know, they don't address former refugee populations, and they definitely don't address the food needs of this population and their cultural assets. And, you know, like being able to grow food themselves. So this was, you know, it's something that's missing, and that needs to be brought to the conversation. So I think, you know, kind of, unsurprisingly, this is, I think, what it looks like in a lot of places that maybe there's more grassroots organizations doing the work, but it's not really in these bigger long term plans yet.

Elisabeth Stowell  31:37 
Well, it is good to hear that maybe Buffalo is headed in the right direction with policy and helping out refugees. And we're very lucky to have people like both of you that are leading in this right direction.

Veronika Semenova  31:52 
Thank you for informing us on the local situation on food systems and sovereignty in Buffalo. Are there other ways that the COVID-19 pandemic has influenced the food systems, food sovereignty, and refugee health?

Dao Kamara  32:08 
Oh, yes. Surely it does have a real big impact on the refugee population in Buffalo, because of the lack of fresh food or culturally relevant food, you find out that a lot of the refugees in Buffalo during the COVID, could not even access, could not access the food that was coming from FeedMore. People will go to FeedMore to get food for their families, but at the end of the day when they're grabbing food, the food ended up in the garbage can. Because they're definitely not used to canned food, not used to plastic food. And the food is not actually fresh - it's not culturally relevant to them. And they get it from FeedMore just as a food for COVID-19. But it made no impact to them. And it was very difficult to even find their own cultural foods in the store. Because of the pandemic, there was shortages of food everywhere. And they couldn't access the kind of food they need. And it was kind of very difficult for a lot of our people to survive through the pandemic because there's lack of medication, people cannot go out but at the same time there's no food that we have that will help them to actually maintain their health. So they begin to decline in their health. People even that through the pandemic lack of because of not being so healthy. So the COVID-19 actually was a huge impact of the refugee and immigrant population. And that's why when PFC came here, right before after the pandemic, people began to say no, we need to jump on board. We need to be able to achieve the full system. We don't have to be in this country to live and to live on canned food. Can we be able not just providing food just for the refugees and immigrants? But how can we be able to provide food for the region and food that will be that will be culturally relevant and fresh food in the food desert era where you cannot find, you cannot find a Walmart, where you cannot find Tops? Or where you cannot find the real grocery store, where you cannot find Wegmans. What can we do to produce such a food because the food that you find in Wegmans, in Walmart, you cannot find that food in our neighborhood, in a poor neighborhood. And if we really don't pay attention to address the food insecurity. After the pandemic, we're still facing the food insecurity as we still go on but we need to work together on how to be able to address it on a regional level, not just on a small scale.

Veronika Semenova  34:42 
Thank you so much for that. Next follow up question is what really reduced those negative outcomes caused by COVID-19 in this specific sector?

Dao Kamara  34:51 
One of the real problems we really need to address is access to land. Access to land. Right now Providence Farm Collective is actually farming under seventy acres of farm land. Under the seventy acres of farmland we actually - I love farming all the land because we have infrastructures on those land, we're about to build up a pavilion, a wash station, a flower station, a commercial kitchen. But on the land that we are actually working on right now, it's community farm and twelve incubator farmers. By 2024, we might be running out of land. What other support? We need support for new farmers actually emerging within Western New York. How can they have access to land on their own? What are the support systems in the entity for the New York State Department of Agriculture that can actually help them to access land, land that will be affordable, land I will stay to be proud to say forever that developers and agricultures will not be able to compete. What can we do to actually be able to support those farmers who are aging out so they can actually be able to pass on those lands to the incoming farmers, what can we do to encourage our new generation that is coming out that they can have interest in farmers who are going to be able to rejoin from even for a department for New York State Department of Education from the resettlement agency to be able to identify immigrants or refugees when they enter this country, not just a trader in factory, but ask them what are the skills that they come with, they may not be educated, but they are from agricultural background where they can be able to contribute to society. Not everyone wants to go into the factory, not everyone would be on a Department of Social Services or cash or cash assistance, but we'll be able to use their skill to contribute to society too as well. So I think although negative impact, we find that and say look, and we have to look at racism too as well. Because racism, it helped to keep people in a poor neighborhood and actually be able to bind people into poverty. So if we all can be able to treat one another on the scale of preference of equality, and look on how to make contribution in this world. And we can work together to address the issue. Everyone will be in a better place.

Elisabeth Stowell  37:11 
Thank you so much, Dao. Alex, do you have anything that you wanted to add on this topic?

Alexandra Judelsohn  37:16 
Yeah, I mean, I agree with everything that Dao said, and you know, especially at the local level, he said, ensure access to land. Obviously, soil in the city comes with a lot of issues. But, so a large percentage of land in the city of Buffalo is vacant, there should be a process that is not opaque for securing it. And, you know, using city land for agricultural uses is completely valid, it doesn't all need to be maintained for a developer to develop someday. And I just think that local governments need to learn to work with refugee communities and listen to rest refugee voices. For example, in Buffalo, we have an Office of New Americans, there's a new staff person, and I don't know who it is yet. But why don't we create a task force with leaders from different former refugee communities so people can actually directly hear the voices and the issues in these communities and a state level refugee advisory committee to give input. And as to what the refugee community needs, someone I talked to for my research, sat in on, there's a weekly meeting of these nine national - they're called national voluntary agencies (VOADs), that administer resettlement services in the US. And they said that this person said, it's kind of like a Sports Draft deciding where people will go, but why don't we listen, like Dao said, to what people bring with them? Everyone has a unique experience and unique skills. And think about that in terms of where people are going to go, you know, does someone have an agrarian background? Let's go someplace where there might be a program to turn over land from a farmer who wants to retire. And thinking, I guess, more holistically, if the refugee resettlement program, you know, the goal is to set people up for success and well being in their new home, you know, 90 days of support. And this program that really just sets people up to become economically self sufficient is not the right way to do things.

Elisabeth Stowell  39:27 
Thank you, Alex, it sounds like both of you agree that there needs to be involvement and support on the government level, but that it needs to come from listening to the actual refugee populations.

Veronika Semenova  39:39 
We were wondering about the next steps for you. Where do you see your future work and research heading towards involving food systems, food sovereignty, and refugee health?

Dao Kamara  39:51 
As for me right now, with Providence Farm Collective and we are actually working on buying our 37 acres of farmland. We hope to close on our capital campaign, this December 31. And we are also in the process of buying farmland. But I will teach others how can we get more farmland so our farmers can be independent, so they can actually be able to be proud of their own work, they can own a farm land, and they can be part of the growth within Western New York. And we are also working on the future. How can we be able to recruit new farmers, encourage new farmers, because farmers are aging out and we still need food to address the food insecurity. So we're working hard to make sure that we can encourage farmers and recruit new farmers within the regions. But at the same time, we're working hard to see how can we work with doctors and health organizations to know the importance of cultural relativism and fresh food. That those foods can be in schools, those foods can be in the hospitals. So that it can be served, that offers a medicine so doctors can actually be able to recognize that okay. Because it is not just any kind of food should be served by the hospital, but those foods should actually be relevant medicine and be culturally relevant to the patient that actually goes to the hospital as well. So where can we come on a table that doctors are honest in their practices, that they will be able to incorporate the farmers, the farmer versus the food that they work with, a hand in hand we can come together to be able to address this issue. And that's where we are going, I think that's the future that we're working towards right now.

Veronika Semenova  41:37 
Thank you for supporting refugee farmers and encouraging them to own their own property. And it's definitely a great point to include medical professionals when it comes to food.

Alexandra Judelsohn  41:50 
Thank you so much for the invitation. This was a lot of fun. I learned a lot.

Sarah Robinson  41:56 
This has been another episode of Buffalo HealthCast. Thank you to our amazing guests, Alexandra Judelsohn and Dao Kamara. Be sure to visit the show notes to learn more about our speakers and the work they do in our community. This episode was written and recorded by Elizabeth Stowell, Veronica Semenova, and Syed Rahman. Our theme music was written and recorded by Dr. Sungmin Shin of the UB Music Department. My name is Sarah Robinson, your production assistant and sound editor for this episode. Buffalo HealthCast is produced by the University at Buffalo School of Public Health and Health Professions. To learn more about health equity in Buffalo, the US, and around the globe, visit our website linked in the show notes to find more episodes. Thanks for listening to another episode of Buffalo HealthCast.

Sarah Robinson  0:02 
Welcome to a special edition episode of Buffalo HealthCast, the official health equity podcast of the University at Buffalo's School of Public Health and Health Professions. This week, we're celebrating National Public Health Week. This year's National Public Health Week topic is Centering and Celebrating Cultures in Health. Our cultures have always shaped our health. We learn from the communities we're born in and that we build together. And for this National Public Health Week, we look to community leaders as our health leaders, we celebrate the unique and joyful ways different cultures focus on health, and we look to how we can learn from each other with humility and openness. Join us for this special episode addressing each daily theme of National Public Health Week. You'll hear from community members, faculty, and University at Buffalo students on topics like violence prevention, mental health, accessibility and more. Be sure to visit the show notes to learn more about each of our guests and the topics discussed in this episode. We hope you enjoy this special edition of Buffalo HealthCast as you celebrate National Public Health Week.

Annamarie Malik  1:07 
My name is Anna, I am a second year MPH student with a concentration in Community Health and Health Behavior. I also work as a teaching assistant for undergraduate public health courses, and a graduate student ambassador for the School of Public Health and Health Professions at UB. I think that the topic of community was chosen as a theme for National Public Health Week because community is an important aspect of public health. We know that many factors influence health, such as where someone lives and what their social circles are. Zipcode, or where you live can help to predict positive or negative health outcomes. So for example, some people living in a certain zip code can have a higher rate of certain cancers as compared to people living in a different zip code. The same goes for your social circle or the people that you interact with. If you surround yourself with people who make healthier choices, you are more likely to make those choices for yourself. So another example, if you are surrounded by friends and family who choose to eat healthier foods or participate in more physical activity, you are more likely to also make those choices for yourself. So eating healthier foods, participating in more physical activity, compared to if you surrounded yourself with people who did not participate in those things. Whether these are active or passive choices is another conversation. But if you surround yourself with people who make healthier choices, you're more likely to make those choices for yourself as a part of the community that you're a part of. So one thing that I want people to know more about this topic is that it can be what you want it to be. Community is defined as a group of people living in the same place or having a particular characteristic in common. So this can become something as broad or as narrow as you want. So for example, community can be defined as the people living in one zip code, or the people living in one city, or one town, or one state. Community can also be defined as the people working in one office, in one location, or the people having the same hair color. Again, something can be as broad or as narrow as you want. You can choose the community that you want to look at, based on what you want to define it as, which is something that I think is nice about the community and characteristics of communities. So things can be learned from looking at different communities and by defining communities in different ways. And sometimes there can be different observations that can be found. So one way that people can get involved in this topic is spending time volunteering in your local community. So by doing this, you're not only helping out in the community, but you're also making connections with the individuals that live there. So many times you learn about their lives and what goes on in the community, including what they are good at and what they can be struggling with. This can help in the aspect of public health because you can either be doing research on what the community, different health outcomes of the community, as well as different health behaviors of the community, you can be looking at the positive and the negative. And by being in the community, you're getting real data from real people with their real lives and what they are either doing good at or what they can be struggling with, what they may be needing help on, what they could be helping people with. Another way that people can get involved in this topic is by going to various community meetings. So this can include board meetings or block club meetings. Again, at these meetings, you make connections with the community and learning more about them in their lives.

Dr. Akua Gyamerah  4:32 
Hi, my name is Dr. Akua Gyamerah, and I'm a social medical scientist in the Department of Community Health and Health Behavior at UB. Our research really aims to understand multi level and intersectional determinants of health disparities among racial, sexual and gender minorities, including how historical and social structural factors such as racism, violence, and criminalization shaped disease outcomes among marginalized groups. My current research examines how experiences of gender based violence impact alcohol use among trans people and cis women in The Bay Area and how intersectional stressors impact mental health and HIV treatment outcomes among sexual and gender minorities in Ghana, West Africa. So why do we think this topic of violence was chosen for National Public Health Week? Well, the United States is home to pervasive violence with various violence outcomes, reaching epidemic proportions and reflecting significant disparities in outcomes, including racial and ethnic disparities and disparities in religion, sexual orientation and gender identity. And other forms of violence highlighted under this theme include gender based violence, police violence, sexual violence and domestic violence. I wanted to talk about just a few statistics just to highlight the scale of the problem. But in the United States, over 1000 people are killed yearly by the police, with black people three times more likely to be killed than white people. Mass shootings have nearly doubled since 2018, with 647 shootings reported in 2022. And as of February of this year, about 95 reported so far. Among undergraduate students, and we're talking about college campuses, like our own, about 26% of females and 7% of males experienced rape and sexual assaults. And of course, we need more data on how LGBTQ students also experienced these forms of violence. In terms of intimate partner violence, one in three women and one in four men have experienced some form of intimate partner violence. And we see disparities related to race when it comes to these statistics, with 45% of black women and 40% of black men reporting experiencing intimate partner violence. For lesbian, gay and bisexual individuals, they experience violence rates higher than straight counterparts. My own research with my colleagues at San Francisco Department of Health found that one in two trans women in the San Francisco Bay Area have experienced transphobic hate crimes with black and Latinx trans women more likely to experience deadly forms of violence, such as assault by a weapon. So these statistics paint a particular picture, which is that there are multiple crises related to violence across the country, and across different social groups that reflect and exacerbate existing social inequities. So what is one thing I want people to know about this topic, given the realities that I just described? I think the key takeaway from this topic is that violence is so pervasive and normalized in this country that it is actually not publicly understood as a key predictor of adverse negative health outcomes. It is just seen as what is, what happens in this country, another mass shooting, here we go again. However, violence is linked to adverse health outcomes. It is both an outcome of social inequalities but also a producer of more social inequalities, right? And because of that, it is a key public health issue that is in need of redress. So, violence is a historical and social structurally produced problem, one that does not only manifest in direct and behavioral ways that we are accustomed to talking about, such as, let's say, physical or sexual violence an individual may experience from another individual, but it is also something that is experienced in distal and indirect ways as well. Right? We often talk about behavioral violence, such as mass shootings, but less about structural violence, and structural violence - I'm going to focus on here, on structural violence. Structural Violence is a term coined by Norwegian sociologists Johan Galtung, and liberation theologians decades ago, that describe ways that our social structures such as the economy, our laws, the political system, religious institutions, and ideology, and so other social cultural factors, prevent individuals, groups and societies from meeting your basic needs and reaching your full potential. And usually it is the most marginalized among us, that are kept from meeting their full capacity and their full needs because of these forms of structural violence. So for example, we talk a lot about individual mass shooters, individual forms of violence, etc. But little conversation, we have little conversation about the political climate, which encourages and normalizes such violence. Now, I want to pause here and focus on the ongoing backlash and attacks against transgender people across the country as an example of this structural violence. Over the past few years, we've witnessed over 400 anti-LGBTQ bills introduced across the country, and 15 anti-trans bills specifically that have been passed into law. These attempts and successes in criminalization is just an example of the structural violence that then cause marginalized people like transgender individuals to experience shortened life outcomes, physical violence, including murder, and blocked access to health care, including gender affirming care, and so forth. The discourse of eradicating transgenderism is what leads to the behavioral violence of massacres of LGBTQ people like that of the Pulse Club massacre in Orlando or Club Q in Colorado Springs recently, or in the case of racist rhetoric and policies, the racial segregation that allowed for white supremacists to massacre black people right here in Buffalo last year. So in addition to kind of understanding and seeing the relationship between behavioral violence and structural violence, also, I want to talk about the need to be critical about how behavioral violence and data related to it is used to also justify structural violence, such as how crime statistics are used to increase police surveillance and violence that then lead to, you know, racial disparities, for example, in police killings. So how can we get involved in addressing these issues or talking about these issues? I think one key thing is that to address violence, at its roots, we need to denormalize both behavioral violence and structural violence and become more sensitized to both. In order to address a problem, we have to recognize that there is a problem. And if we've normalized something, we do not recognize it as an issue, but rather a factor of society. But if we want to see violence, we need to see violence as both an effect and a problem that needs to be addressed. So that's one thing I want to I want to say. I think we also, as people in public health, as professionals of public health and students of public health, we need structural solutions, like social welfare programs that work to eliminate the socio economic inequalities for what I've described as structural violence. Programs like this have shown to reduce behavioral and community violence, and other forms of violence that may produce, right? So we need positive programs, programs that contribute to building up rather than breaking down, programs, social welfare programs that help eliminate social economic inequalities, can then help address violence that are produced by these forms of structural violence. We also need to eliminate laws that dehumanize marginalized groups such as these anti LGBTQ bills that are being proposed and implemented, laws that dehumanize minorities, racial and ethnic groups, such as, you know, anti immigration laws, the violence at the border, laws that can incarcerate people for, you know, acts that are a product of needing to survive, right? So petty crimes, etc. We need to change laws like that, and move funding from criminalization to funding to social programs that help people thrive and help communities thrive. Right. So, you know, I think these are some of the examples of how we can actually shift our focus from implementing structural violence policies, to investing in policies that bring resources, bring funding into our communities to help folks meet their needs, and thrive and so forth. So those are kind of the two things I think we need to do to address the issues and ways that we can get involved kind of advocating for policies like these. Thank you so much, and Happy National Public Health.

Danise Wilson  13:36 
My name is Danise Wilson, and I am the Executive Director of Erie Niagara Area Health Education Center, AHEC for short, where we focus on diversifying and educating future and current health professionals, while increasing health literacy within medically underserved communities. Reproductive and sexual health was chosen for National Public Health Week because we know that health is not just the absence of disease. Creating a positive and respectful approach to sexuality and sexual health must be a public health matter if we are to achieve optimal health. Women and men should be provided with early education, resources and access to ensure that they have safe, informed, affordable reproductive options of their choice. Good reproductive health increases overall wellbeing, decreases poverty, increases economic growth and ultimately impacts generations to come. One thing I will want people to know about reproductive and sexual health is that it was reported that 25 million abortions were performed in unsafe conditions. And of that number, 3 million were between the ages of 15 and 19. It should be a public health priority to ensure that everyone is able to avoid pregnancy until they're ready, to terminate an unwanted pregnancy, and have a safe, full-term pregnancy if they choose, regardless of socioeconomic status, societal norms, gender relations, sexual preference and laws. What can you do to get involved in this issue? Get involved! You should reach out to your local, state and elected policy makers and encourage them to support comprehensive sexual and reproductive health legislation, you should join and consider donating to organizations who are in the reproductive health space such as Reproductive Health Access Project, Sister Song, Physicians for Reproductive Health, and Centers for Reproductive Rights. Together, we can make a global impact on sexual and reproductive health and rights.

Dr. Christine Linkie  15:48 
Hi, I'm Dr. Christine Linkie, and I'm a clinical assistant professor in the occupational therapy program of Rehabilitation Sciences in the School of Public Health. Occupational therapists work in psychiatric units, we work in community based mental health, we work in outpatient clinics, and it's all about function. Occupation means the things that we do to occupy our time. So it's all about helping people to develop the skills. But not only that, it's also to develop a sense of wellness and quality of life. I was asked why do I think that mental health was chosen as a topic for this podcast? I have two answers for that. But the first one is that, as probably a lot of people know, there's good evidence to show that mental health of young people and adults since the pandemic has really become more of an issue. And we see more people struggling with mental health challenges. So that's the first reason why I think and the first thing that I want to talk about for a minute. And the other reason that I think it may have been chosen is that for people who have serious mental illness, so that is like schizophrenia, bipolar disorder, and also substance use disorder. We are in need of services for them, and making sure that folks truly get the help that they need to live the full productive lives that they love. Let me talk first more globally about mental health and the pandemic. So when I was thinking about this, and the research is really showing that people are struggling more, one of the things that occurred to me is that we have reason to be hopeful. Because at the same time that people are struggling more, there are things that everyone can do, no matter what, where you live, or you know, whether you're in a rural area or in an urban area, there's things that everyone can do. So I am an Occupational Therapist, and in occupational therapy, occupation doesn't mean job. Occupation means how we occupy our time. And that can be everything from your morning routine to caring for children to going to a worship service, how you occupy your time, and there's research more and more to show that that - how we occupy our time, occupational engagement is linked to mental health and wellness. So that to me is very hopeful, because that means that all of us can be doing things ourselves and supporting each other in doing things that are meaningful to us as a way to improve our own mental health. And also keeping in mind occupational balance. So what is meaningful for me, and how occupied I am is going to be very different for someone else. Right? So keeping in mind occupational balance. And the other reason why I'm really hopeful is that there is research to show that in terms of caring for our young people, a meaningful relationship with one caring adult is a protective factor against developing mental health challenges. So to me that says that any of us can be that one caring adult. So that's something that we can do. So why am I hopeful about working with people who have serious mental illness and people who have drug abuse challenges? Well, for a number of reasons, first of all, our governor and our budget, our state budget, have dedicated increased funding for supportive services, and I think we're going to see that happen more. I also see that here locally in Western New York and across the state, there is more of a commitment to services and it's interdisciplinary. So it's occupational therapists, psychiatrists, social workers, counselors, and people who don't have degrees, all working together to support mental health services, and it's peers also. So peer-based services are really important too. So knowing the folks who work in these areas, and the commitment to it, I am hopeful. So in both of these areas, both for mental health on an everyday level, there's things that we all can do. And there's things that we can also support services for people who have serious mental illness and substance use disorders. So I encourage everyone to get involved, to take care of your own mental health and to take care of each other. If you or someone you know is experiencing a mental health crisis, that you can call 988. You can also go on the website 988.org. It's a really good resource where you can find different resources to support mental health.

Dr. Frank Cerny  21:21 
I'm Dr. Frank Cerny, Professor Emeritus in the Department of Pediatrics, School of Medicine at the University at Buffalo, and Emeritus Professor in the School of Public Health and Health Professions at the University at Buffalo. My career started as an exercise physiologist specializing in pediatric and pediatric diseases at Children's Hospital in Buffalo. I eventually moved to the University at Buffalo, and became Chair of the Department of Physical Therapy, Exercise and Nutrition Sciences. I retired from that academic career and research career and took up the task of looking at factors that were affecting our rural populations, as it regards to the intersection of poverty and health. I think the topic of rural health is critical as we discuss public health, particularly during this month where we focus on it. Rural health has been ignored for too many years, there's been very little public or private investment in our rural communities. That's resulted in a loss of hospital care, primary care, and certainly specialty care in rural areas. In my current role, as the executive director of the Rural Outreach Center, we've recognized the intersection between poverty and public health and health in general, such that the, what we are now calling the social determinants of health, are the same as the antecedents and consequences of poverty. So at the Rural Outreach Center, by addressing one, let's say, poverty issues related to transportation, and cash reserves, and housing and so on, we're ultimately addressing the public health issue. We've come up with a mechanism to address multiple issues that these rural residents are facing, and come up with a model where we put all of these things together into one package so that we're not addressing silos, we're addressing these issues in conjunction with one another very effectively. We are changing the situation of families and children in particular to try to break the cycle of rural poverty. So this lack of investment in our rural areas has resulted in a decreased availability of health care resources. And because of the rural nature of our population, accessibility is an issue, transportation. There's no public transportation in our rural areas. And for instance, in the area we serve, which includes about 45,000 people in poverty, 8500 of those people have no access to transportation. So transportation is a huge issue that we have addressed fairly effectively. What most people don't know about rural health is that the incidence, not the absolute numbers, but the incidence of most issues related to public health is higher in rural areas. The incidence of domestic violence is higher than in metropolitan areas. The incidence of chronic diseases is higher in rural areas, and that includes chronic lung disease, diabetes, and so on. The incidence of teenage pregnancy is higher in rural areas than metropolitan areas, all of these things come together to reach a point where the needs, the health needs in our rural areas are tremendous. But they're being inadequately addressed, leading to a large health disparity between health, health outcomes in rural residents and residents of metropolitan areas. So if we look at the the most common disease entities that we see in our rural areas, cancer, COPD, heart disease, and so on, a lot of this can be attributed, certainly to the lack of care. But the genesis of these disease entities comes from the fact that many of these rural areas are where they cite landfills, and there's a toxic runoff from those landfills. There's a large use of pesticides, herbicides and fertilizers that pollutes the both the air and the groundwater. These folks deal with wells with no fluoridation. So dental disease is a big issue. So we need to begin to pay attention to this population and those things that contribute to these health disparities. So what could what could you do? What could we do together? Number one, you can advocate for rural populations, there have been few people advocating for addressing these rural health disparities. In your professional involvement, you can ask for a seat at the table for people representing rural areas so that their voices are heard and their concerns can be can be shared. You can try to be a seat at the table and have a voice for rural areas, when policy, health policy and so on, health policies are being made. So these voices are heard and the more unique solutions to address these issues can be formulated.

Dr. Albina Minlikeeva  27:26 
Hello, my name is Albina Minlikeeva, and I'm a clinical assistant professor at the Department of Epidemiology and Environmental Health. I also teach in the undergraduate public health program, and involved in some disability-related work. Approximately 26% of the United States adult population report having disability. This population is disproportionately affected by various health disparities. They experience high prevalence of various behavioral risk factors, for example, smoking, e-cigarette use, unfavorable dietary habits, and insufficient physical activity. The findings of various research studies also found that people with disabilities are at a higher risk of developing heart disease, diabetes, depression, and high blood pressure. They also experienced oral health disparities. Altogether, these unfavorable health-related issues result in the higher mortality experienced by people with disabilities compared to people with no disabilities. They also are affected by the social determinants of health at a large extent, compared to individuals with disabilities. People with disabilities report having fewer friends, less social support, they experience environmental barriers, including inaccessibility of the buildings and lack of educational opportunities. This population is also at the higher risk of being unemployed, and receiving lower salaries compared to people with no disabilities. They also experienced a limited health care access. According to the CDC, only one in four adults with disabilities report seeing healthcare providers on a regular basis. And one in every five adults with disabilities report having their health care needs being unmet because of the cost of medical care. Stigmatization, ableism, implicit and explicit biases directed at people with disabilities can significantly affect their health. Public health plays a fundamental role in advancing health equity among people with disabilities through incorporation on various programs that are related to health promotion and disease prevention. The strategies that address various environmental and social factors affecting this population, promoting inclusion of people with disabilities through public health programs, and the participation in social activities can foster health equity and address health disparities in this population. Some ways to make contribution in promoting health equity among people with disabilities could be being a volunteer and helping local organizations, working with people with disabilities, attending local events that are hosted by these organizations, and also include people with disabilities in dealing with social activities and events. Together, we can make a difference and promote health by all individuals.

Dr. Jenn Temple  30:33 
Hi, my name is Jenn Temple, and I'm a professor in the Departments of Exercise and Nutrition Sciences, and Community Health and Health Behavior at the University at Buffalo. I'm also the director of the Nutrition and Health Research Lab. And the work that we do in the Nutrition and Health Research Lab is really centered on understanding factors that influence food choice and eating behavior. And the recent work that we've been doing has really focused on lower income populations, and trying to understand factors that influence their food decision making, such as neighborhood food environment, home food, environment, and food insecurity. So I think the topic of nutrition and eating was chosen for Public Health Week because food and nutrition and eating are really the foundations of good health. And when people make poor eating decisions, or don't have access to healthy food, it contributes to chronic disease and also exacerbates health disparities. And so eating and equitable access to healthy food should really be the cornerstone of public health practice, and a public policy in order to ensure that people have the ability to live their healthiest lives. One thing that I want people to understand about food choice and eating is that it's really complicated. And there's a number of different factors that can influence the choices that people make about food and how much they eat, and that these factors can change across the lifespan. So one of my recently graduated PhD students, Amanda Ziegler, really focused on this for her dissertation work. She was trying to understand the decision making that adolescents are making when they're choosing their food. And one of the things that she found out is that there's a lot of different reasons that adolescents make food decisions. And so things like ease of preparation, preference, healthfulness, availability, time that it takes in their schedule, how hungry they are, things like that are are all kind of influencing one another and influencing the food choice that adolescents are making. And when we think about families, it can be even more complex, because families and parents, they're thinking about what they have access to, what they have time to prepare, what they have the knowledge to prepare for their families, they also might be thinking about what their kids will actually eat. So we hear from parents all the time that like, oh, I have one picky eater and one kid that'll eat anything. And all of these competing factors really make it really stressful for families to figure out what to prepare for their kids for meals. One of the other things that I would like people to know is really, it's very harmful to judge people. So one of the things we hear from lower income families all the time is that they feel very judged. Like for example, if they were taking their kids to McDonald's for dinner, they might get some looks from people or people might pass judgment on them for making their choice. But for a family that might have a limited amount of time, a limited amount of money, kids who are hungry and want food kind of right then and there. McDonald's might be the best choice for that family at that time. And it might be a way that can alleviate some stress that a family has about feeding their kids. And so it's really harmful when we judge people for these food decisions that they're making, also for their body weight. And, you know, where they're eating and how they're eating and how they're feeding their families. And so I would urge everyone to have have more compassion for people in these situations. In terms of what people can do to get involved with this issue, I think it's really important that we do everything that we can to improve access to healthy food for people in all communities. So in the Buffalo area, there are community gardens that people can help with, and maybe starting a community garden. We also have a mobile market program that is headed by Dr. Lucia Leone. So getting involved with that may be helping to get the word out about that or get involved, volunteer with some of that mobile market delivery. That could be helpful. And then I think just again, as I mentioned earlier, having more compassion for people that are living in lower income situations and maybe not passing judgment on the food choices they're making or their body weight. Even that alone, trying to reduce stigma, about weight and about people's food choices, that alone can help at least address some of the mental health burden that some of these things can bring up.

Sarah Robinson  35:07 
This has been a special edition episode of Buffalo HealthCast. Thank you to our amazing guests. Annamarie Malik, Dr. Akua Gyamerah, Danise Wilson, Dr. Christine Linkie, Dr. Frank Cerny, Dr. Albina Minlikeeva, and Dr. Jenn Temple. Be sure to visit the show notes to learn more about our speakers and the work they do in our community. This episode was produced by the University at Buffalo School of Public Health and Health Professions, and our theme music was written and recorded by Dr. Sungmin Shin of the UB Music Department. I'm Sarah Robinson, your production assistant and sound editor. To learn more about health equity in Buffalo, the US and around the globe, visit our website, linked in the show notes to find more episodes. Thanks for listening to another episode of Buffalo HealthCast.

Intro  0:01 
Welcome to Buffalo HealthCast, the official health equity podcast of the University at Buffalo's School of Public Health and Health Professions. In this podcast, we cover topics related to health equity in Buffalo, the US, and globally. This season, we'll take a look at food insecurity and health equity on a global scale. You'll hear from experts around the world who specialize in areas like urban agriculture and food contamination, soil science, food sovereignty, refugee health, intensive agriculture, and more. This season's episodes were completed in Dr. Kasia Kordas' Global Health class, a graduate level course offered at the University at Buffalo, and produced by the School of Public Health and Health Professions.

Nicholas Levano  1:02 
Hello, everyone, my name is Nicolas Levano, and today I'm joined with my colleagues Danielle Nerber, and Nikitha Cothari, as well as our guest speaker, Dr. Nadia Koyratty. Our topic of discussion today is food and water insecurity and how they impact child development, health and daily living. Dr. Nadia Koyratty is currently an Associate Research Fellow at the International Food Policy Research Institute. Her work encompasses nutrition, food security, and health in low- and middle-income countries. As a Postdoctoral Research Associate at the University of Maryland in Baltimore County, she has worked on food security during disruptive events such as natural hazards and public health emergencies, such as the recent COVID-19 pandemic. Dr. Koyratty obtained a PhD in Epidemiology from the University at Buffalo, and has a Master's degree in Sustainable Management of Food Quality from the University of Montpellier in France, and from the University of Basilicata in Italy. Her research interests include food sciences, food insecurity, water insecurity, and nutrition interventions in low- and middle-income countries. Thank you for joining us today, Dr. Koyratty.

Dr. Nadia Koyratty  2:05 
Thank you for having me.

Nicholas Levano  2:10 
So I want to start off about talking with water insecurity. And for many of us who grew up with access to clean and safe drinking water, we often take this for granted and how much of a privilege this is, because it also affects how we perceive the burden of water insecurity. According to UNICEF, if we look at the global burden of food and water insecurity, we see that one in five children do not have access to enough water to meet their everyday needs. And at least 40 million children are severely nutrition insecure. According to you, and based on your experience, what are some of the factors that contribute to water stress, Dr. Koyratty?

Dr. Nadia Koyratty  2:43 
So, I would like to address the definition first, of food and water insecurity. Because the statistics that you have given address one portion of food and water insecurity, but it by no means covers the whole aspect of what food insecurity means. So food insecurity covers or refers to availability to food, access to food, which can be financial, social, or physical, and acceptability of food, which refers to if you think about the cultural context, is the food adequate or acceptable to eat? You have vegetarian, you have people who are restricted by their religions, you have people who are restricted by their ethical beliefs. So all of that is part of the acceptability of food, which forms part of food insecurity. There's also the aspect of utilization. And by utilization, I mean, how to prepare food, when the food is actually beneficial to you, since we're talking about children, to the child, and at what ages and what kinds of foods are good for the child to biosynthesize the food for their nutritive value, and reliability as well, because the food that is accessible and available and acceptable, need to be available regularly, they can't be sporadic. There needs to be constant access to acceptable and preferred foods. So that's one aspect. And often when you look at the literature, food insecurity is measured with respect to economic and financial access. So the state of food security and nutrition in the world, that's called SOFI, the SOFI report focuses mostly on undernutrition, undernourishment, overweight or obesity for children food security assessment. It wasn't until very recently that they started using the food insecurity experience scale to assess food insecurity as a whole. But even then they still focused on the economic and financial aspect of food insecurity. And that was at the household or individual level, not at the child level. So there's still some work to be done to actually determine what constitutes food insecurity among children. Because if you look only at the household, food insecurity of the household does not determine food insecurity at the child level, because there are differences in what is allocated to the child in terms of quality and quantity. And that is not covered in the current measurements. And like you said, Nicholas, about 25% of children under five, worldwide are affected, but that's in relation to undernutrition, such as stunting and wasting. Food insecurity itself is not measured.

Danielle Nerber  6:10 
Something you said just a few minutes ago, you talked about how important it is for consistency and kind of making sure that we're addressing this at the beginning. In our research, we came across UNICEF, of course, and how they have this whole idea of the first 1000 days, which is that critical window to ensure that children survive and thrive. What do you think about that idea, and how it kind of relates globally?

Dr. Nadia Koyratty  6:39 
Well, that's an excellent question. The 1000 days is absolutely a critical period, during which we need to address both food and water insecurity, because based on the flowchart, on the pathway to child undernutrition, or child growth and development, food and water are the other resources that underlie the type of environment in which the child grows and develops. And because poor child growth occurs in utero, we have to focus on the mothers as well, and the mother-to-be during the pregnancy period, which constitute the nine months in the 1000 day period. So mothers need to have access to proper food and safe water, because otherwise that affects the development of the fetus and eventually of the child. And we've seen as well that once a child is born at low birth weight that affects his or her trajectory over time in terms of growth. And there are a lot of implications for this because it affects the physical growth of the child, but also the motor and social skills, the education attainment, the cognitive function, and so on. So definitely the 1000 day window is adequate to intervene. But that said, I don't want to diminish the other time periods during which interventions are still useful. Above five years of age, for example, while the child is growing, because you can't focus on only one timeframe and expect everything to change over time. You need consistency and the 1000 days is going to work one generation and to consistently provide food insecurity over time ensures that multiple generations are protected and are healthy.

Nicholas Levano  8:44 
Well, one thing you actually touched on was how environment is also an important factor when it comes to food insecurity. And also how financial situations and accessibility are important to child development. So I was wondering, how does the role of food deserts impact or influence adequate nutrition and development in children?

Dr. Nadia Koyratty  9:04 
So food deserts, that's a different beast, because food deserts are very common here in the US. And we've seen that a lot of people will access foods or will have only access to foods that are not generally healthy. Because the shops that are around them, the corner stores, don't have the foods that they need. On the other hand, food deserts in lower and middle income countries, comes mostly as issues with farming, with droughts and flooding, where the farming community are not able to produce as much as they can to eat themselves, and to sell for their households to survive. Does that answer your question?

Nicholas Levano  9:52 
Yes it does, it actually reminds me of a concept that we've talked about in our classes related to global health. It's the concept of the Global North and South divide. Basically, this concept covers that typically developed and high income countries have the means to intervene, while low and underdeveloped nations tend to face the burden of these issues. So based on this concept, where do we see these issues of water insecurity and food insecurity seem to be most pressing in the world?

Dr. Nadia Koyratty  10:21 
Surprisingly, for me, from what I've observed working in both high- and low-middle income countries, both areas, both regions have their specificities and their issues. It's not that one is better than the other. No, you have to consider the context of the region, like you said. Higher income countries may be able to intervene and address issues easier. But the political situation sometimes hinders that in high income countries. Whereas in low income countries, the issue is a lot of donors and international organizations are the ones that intervene. Governments are often in support of those interventions, or of those help that are provided to address food or water insecurity. So unless and until governments of all the countries whether high- or low-middle income countries come together to address the issues that are most pressing in terms of food access and water access. I think we'll continue seeing issues in terms of child health related to food and water. I also want to stress again, the fact that it's not only low-middle income countries that have food insecurity issues or water insecurity issues. The problem is very widespread and quite significant, even in the US.

Nicholas Levano  11:49 
Yeah, this is a very important concept to touch on, especially because as people who've grown around areas where they have access to safe drinking water, and also available access to healthy food options, they may not recognize how widespread this issue really is. When we think about water insecurity and food insecurity, we tend to often think of them as separate issues. However, we recognize that there are overlapping factors that contribute to them. What is the relationship that exists between water insecurity and food insecurity, and how one might promote the other?

Dr. Nadia Koyratty  12:21 
So, similar to food insecurity, water insecurity also encompasses different aspects. So water has to be available for households to be water secure, the water has to be of adequate quality in terms of the smell, the taste, and it has to be safe in terms of the microbiological contaminants, levels of microbiological contaminants, to be safe, and the water has to be reliably accessible. And like food, it has to be stable over time, you have to have consistent access to water to be water secure. And in terms of accessibility, I would like to stress the physical accessibility in low-middle income countries. Because a lot of times in rural areas specifically, there are no water systems, as you have here or in higher income countries. So piping systems are not as developed as they are in other countries. So again, water insecurity encompasses all of that - availability, accessibility, quality, safety, reliability. And when thinking about those things, each individual component of water security will affect different aspects of food security. My favorite example to give is always you need to be water secure, to be able to cook the foods that you need. So what do you need when cooking food? You need to prepare the food, you need to clean it, you need to wash it to ensure that the food is safe to cook, you need to clean your utensils, you can't use the same over and over again, you have to have clean utensils. And to do that, you need water. So in a way water security enables the process of cooking and preparing food. And another example would be different types of food requires different processing or culturally acceptable ways to prepare that food. For example, if you're eating beans, often they have to be boiled. There are different types of other foods that you cook either in oil or you steam them. So you have to consider again the cultural context. What is acceptable and what is usual for the people to eat. You can't just go there and tell them they need to prepare their food differently or they need to eat different things. So we have to make sure that the water that is available to them is adequate to prepare their food. So that's one way. And in terms of hygiene that is also related, because you need water to wash your hands, again, to clean your utensils, so that the foods that you cook are actually safe for people to eat.

Nicholas Levano  15:24 

One important topic that you talked about with cultural practices, and especially in low income nations, or underdeveloped nations that don't have the proper infrastructure or access to water, we see that water collecting is common practice in these regions. And how does water collecting affect children's safety?

Dr. Nadia Koyratty  15:46 
Oh, I love this question. So during my work on food and water insecurity, I came across a lot of different aspects in which water insecurity affects child's health and in different ways. So in countries where the water sources are far away from the households, it's often the responsibility of the child to go and fetch water, that's one. And often that child will be a girl rather than a boy child. And this affects the child's safety in terms of their physical safety, they may fall while fetching water, they may hurt themselves, because where they have to go get water isn't properly paved, for example. The other thing that I found was that mothers who go to fetch water, they often leave their children at home, either without supervision or under the supervision of younger siblings. Now, this is an issue because if something happens to that child, there will be no adult to help out or to guide them. So these are two main ways in which water insecurity or having poor physical access to water can affect directly the child's physical health. But there's also the aspect of child education, like I said, because water is sometimes very far away, you'll find in certain countries, they take up to five to seven hours of walking to get to the water sources. And like I said, also, often it's the children's responsibility to get water because the parents have other things to take care of. And that increases the level of absenteeism in schools. And sometimes the children are just taken out of school altogether and don't get the education that they deserve.

Nicholas Levano  17:52 
Yeah. So you mentioned the gender discrepancy. And I wonder how that physical stress of collecting water is toward pregnant women and how that affects developing children that they're carrying?

Dr. Nadia Koyratty  18:01 
Yeah, yeah, I did cover that in one of my papers, where fetal development is affected because of the load of carrying water. And that there is no explanation for that other than it's heavy, it hurts the person, they may have back issues, which has been reported before, they may have back issues, they may fall because of the load of water that they're carrying, they may have to walk too far to get access to water and thus affect their ability to take care of themselves to feed themselves adequately. Fetal development has actually been shown to be affected by the distance by which pregnant women have to walk to get water.

Nicholas Levano  18:48 
But it's very important that it's also recognized that there's also physical hazards that present barriers to children's health, especially absenteeism, how you mentioned that, because of the long distance they have to cover, children are losing days in school, which affects their education level. And we know how important education is when we talk about determinants of health.

Dr. Nadia Koyratty  19:07 
Absolutely, and eventually it affects the economic development and the population development as a whole of the country.

Nicholas Levano  19:16 
Have you seen any documented research in regards to how food and water insecurity and malnutrition - what it does to the health of a child?

Dr. Nadia Koyratty  19:24 
Yeah, so food and water, like I said, are resources that form part of an environment in which the child grows and develops. So if you have inadequate resources, including food and water, that leads to different health issues. For example, stunting is an indication of the poor resources, whether it's just food or water or other kinds of resources. And food insecurity and water insecurity has been shown to affect early child development in terms of things like social development, speech attachment to parents, cognitive development where IQ levels are lower among those who have food and water insecurity in their environment. It cannot, further down the line, when you look at a lifecycle approach, it also affects the types of diseases that the child gets, and the wages that the child gets eventually when they grow up, and the type of economic influence it has over the population as a whole. Those are documented impacts that you can find in all of the literature on early child development.

Danielle Nerber  20:58 
So we're going to switch gears now, I'd like to talk a little bit more about some real time issues that have been kind of happening around the globe lately and the impacts and dive a little bit deeper into Dr. Koyratty, your particular research and interests.

Nikitha Cothari  21:18 
Hi, I'd like to ask my first question from the COVID perspective. So now we know that COVID caused a lot of hardships and people all over the world, both in high income and low-middle income countries. So you've done some research on what the pandemic has done in relation to food insecurity. Do you mind sharing about that a little bit?

Dr. Nadia Koyratty  21:38 
Absolutely not. So the research that I did on disasters included both natural disasters such as hurricanes and tornadoes, and COVID-19. So COVID-19, in particular, because it was labeled as a public health emergency, I actually did a few in depth interviews with different people who everyone was affected by COVID. But I did interviews with different people to get an idea of the experiences that they had with respect to food insecurity during COVID. And a lot - there's so much to talk about. First, a lot of people lost their jobs. I mean, we all know that a lot of people lost their jobs, and they had reduced income. And with reduced incomes, often it's the food that gets sacrificed first. So lower quality or cheaper food products are bought, rather than what people would normally like to buy, for many reasons, because - either because their economic or financial capacity is reduced, because they have to pay the mortgage, they have to pay the electric bill, the water bill, whatever it is. So financial, and economic hardship affects food insecurity, in terms of access, economic access, and the quality of food that is eaten and the preference associated. And during COVID, we also saw increased prices on certain foods, on certain food items. For example, in New York City, eggs increased in prices by, I think, 35 or 40%. Now, eggs are kind of a basic thing for most people. And the fact that the prices increased affected, obviously people's purchasing habits. There was also issues with markets, generally, the food markets where imports were affected. Not enough food was being imported into the country, or if it was, it was stuck somewhere without being able to enter the country. So one example is Mauritius, where a lot of food is imported from other countries outside of the island. And the ships that brought in the food were stuck at the port because of COVID. So they couldn't unload the foods. So that definitely affects what foods are available on the market as well. And in terms of food processing, so COVID affected the whole food system. And I touched on the markets, the prices, and I will also touch on the production side. We saw that meat production had halted at some point in time in the US, and that was because certain workers in the meat production line were affected by COVID and they had to shut everything down and make sure that the disease didn't spread. So that affected the availability of meat on the market and hence the prices of meat as well. And we also saw that there was a huge loss in milk. I'm not sure what the issue was, but it happened during COVID, where a lot of milk was thrown out.

Nikitha Cothari  25:21 
In keeping with the theme of impact of disasters and food security, I believe you also have an interest in more national hazards such as climate change. What kind of impacts are we seeing globally in families and children in relation to this?

Dr. Nadia Koyratty  25:36 
Yeah, so climate change leads to a lot of natural hazards. We've seen that - droughts, floods, increased tornadoes, hurricanes, wildfires, and as we've seen recently in Buffalo, snowstorms. All of these natural hazards, obviously, will impact food access, because they impact the whole food system. I'll give an example of some interviews that I did with victims of Hurricane Florence in North Carolina. So because of the hurricane, a lot of people reported closed roads, roads that were flooded, roads that were damaged, that prevented them to access food stores. That's one way. The second way was, several people said that their house was destroyed, their kitchen was destroyed. So you can't expect people to be able to cook without the basic necessities like a stove. Or you can't expect people to have access to save food, when their fridge is not working because of power outages or loss of electricity. So these were some ways in which food insecurity is impacted during natural disasters here in the US, and also because of different road closures or monitoring of specific areas, sometimes, trucks, food trucks that bring food to families that are affected by natural disasters can't get through, they can't get to the affected communities. The one thing that was good was that communities that are very cohesive, they will share the food that they have. One particular person, it was a very emotional interview, one particular person said that they lost their home completely. And they were walking around aimlessly trying to find other people. And they came across a house that was partially in good condition. And there was someone there cooking, and that person invited them over to have lunch or dinner with them. So the sharing component also comes into play. Yes, food insecurity is affected, but it can be helped or it can be - the effects can be lowered with help from communities and from different areas, from different people, from different organizations. Food production and food access or food availability is also affected during natural disasters. For example, food stores, like I said, if there's a power outage or you lost electricity, or you lose electricity. Even the stores lose electricity, right? So everything that's in the freezer is lost. And all that's available are foods on the shelf. And all that people can access and eat are foods on the shelf. And sometimes that's not fruits and vegetables. Sometimes that's food that is not nutritionally adequate. Sometimes that's food that needs to be cooked but then you can't cook because you don't have the basic stove or kitchen equipment. I think that covers high income countries. In low income countries, we've seen that disasters, well, natural disasters like droughts affect many different countries. When I was in Zimbabwe, for example, and working on food insecurity, there were crises in terms of rainfall, where for two years subsequently, the rain fell. The rainfall was behind the time, so if the rain was supposed to fall in October, it fell instead in December, so that affected the harvesting of products, of food products. The planting season, it affected the lean season, it affected the hungry season in the community. So people were harvesting less than than they would normally. And that obviously led to food insecurity, especially among the rural populations, but also among the urban populations because they obtain their food from the rural areas. And if the rural areas are producing less, that means less is available for the urban areas because they will keep most of it for themselves to eat.

Danielle Nerber  30:22 
And I'd like to start wrapping it up a little bit and just kind of focus a little bit more on what you do think will be good possible solutions and promising interventions that might be out there to help with food and water insecurity, particularly as it pertains to child health. And the one project that I came across that I believe you got to see firsthand in Zimbabwe, was the Shine Project, which is also known as the Sanitation Hygiene Infant Feeding Efficacy Project. Could you kind of talk about what that trial was aiming for and what that experience of traveling there was like for you?

Dr. Nadia Koyratty  31:02 
Sure. So being in Zimbabwe was great. That was one good experience. Working with the Shine, so I wasn't involved in the development of the Shine trial, I was part of it when it was wrapping up. And the main objective of the Shine trial was to address stunting among children and anemia among pregnant women. So they did a randomized control trial that involved infant feeding practices. So that included education to mothers of newly born children, and breastfeeding and water. The second intervention was water, sanitation, and hygiene. So for this intervention, they focused on encouraging people to treat their water before drinking, on hand washing for hygiene, and on building toilets for sanitation. And those two interventions were also combined. So we had the standard of care arm, the infant feeding arm, the wash arm, the water/sanitation/hygiene arm, and the fourth arm included both the infant feeding and the water sanitation and hygiene intervention. So the purpose was to see what effect the combined food, the combined nutrition intervention, and the wash intervention would have on stunting, whether it actually improved the incidence of stunting in children and whether it improved anemia in the mothers. The one thing I would say is that the intervention was not on food insecurity. And the intervention was not on water insecurity. Like I mentioned, their nutrition intervention included breastfeeding and complementary feeding education, and the water intervention included treating the water. So in terms of water insecurity, the wash arm only addressed safety of water, safety and quality of water, because they showed the households that participated, how to treat their water and why they should be drinking clean water. And the nutrition intervention was to educate mothers on how to breastfeed and what to feed their children after six months of age. So there's definitely things that they did that showed improvement. But as a whole, they did not address food insecurity and water insecurity with all the aspects that I mentioned before.

Danielle Nerber  33:56 
Thank you for sharing that. And I think what you just shared kind of beautifully connects to some of the points that we made earlier, one being when we brought up the first 1000 days, it sounds like the Shine Project, you know, attempted to kind of take into account the breastfeeding issue and how to kind of address it early on. But like you said, it's about consistency. It's about carrying on those interventions past those 1000 days into early childhood, into adolescence, and so on. And the same idea of how water and food are so interconnected and how it's important to address both of them. And it sounds like with this project, it kind of, like you said, lacked the ability to change the infrastructure in the built environment, and really kind of hone in on maybe the root causes of water and food insecurity. So with that being said, I know this is going to be a big broad question to end with, but what do you see as sustainable interventions? More particularly, I guess, for low and middle income countries where resources might not be as available, what kind of would be your dream idea of how to attempt to fix these solutions, particularly as it pertains to child health?

Dr. Nadia Koyratty  35:14 
Hmm, that's a great question. And I think the first thing I would like to address in your question was when you said, lack of resources, that is not really true in most of the lower middle income countries that I have visited. The resources are definitely there. It's utilization of those resources to address food and water insecurity that is lacking the resources in terms of the physical availability of things on the technical skills available, those are there, those are present, what we lack is commitment from different entities, policies to address these issues. And the way I see things forward is not with a single intervention, either for food or water insecurity, like I mentioned, because food insecurity and water insecurity have so many different aspects, availability, access, reliability, quality, safety, utilization, all of these are needed for security related to food and water. So the idea that I have is to focus on the food system as a whole. So address all the sources from the beginning to the end user. And ensure that every step of the way is optimized and efficient to ensure that no person is food insecure, or water insecure. And once you've addressed the system as a whole, I'm not saying this is going to take two minutes, but it's definitely going to take years of practice and of interventions at each level to reach an environment that is adequate for the child to grow healthily, and for adequate development of the population. And again, I think the endpoint shouldn't be just the child, it should be the population as a whole, and you start with a child or you start with the pregnant women first. But that has an intergenerational effect, just like if you approach food and water insecurity as in a system, dynamics modeling for instance.

Danielle Nerber  37:52 
I want to reiterate and I thank you for clarifying that these countries like you said, they do have the resources, it's just figuring out how to utilize it, how to make those connections and how to build capacity in the communities because ultimately, I think that's how sustainable and effective programs are going to be created in order to help the situation. Thank you so much for joining us and sharing all your knowledge, it was absolutely a pleasure. Does anybody have any last minute thoughts or ideas? Nadia, you as well, if you have anything you want to wrap it up with, that would be great.

Dr. Nadia Koyratty  38:35 
No, not that I can think of, maybe just be aware of your peers who may be food and water insecure. There are a lot of people even at college level who are food insecure. And they may be embarrassed to share that information, but you can always share the resources that UB has available for addressing or for helping people who are food insecure.

Sarah Robinson  39:15 
This has been another episode of Buffalo HealthCast. Thank you to our guest Dr. Nadia Koyratty, for taking the time to be featured on our podcast today. This episode was written and recorded by Nicholas Levano, Danielle Nerber, and Nikitha Cothari for Dr. Kasia Kordas' Global Health class in the Fall of 2022. Our theme music was written and recorded by Sungmin Shin, of the UB Music Department. I'm Sarah Robinson, your production assistant and sound editor for this month's episode. Join us next time on Buffalo HealthCast to learn more about health equity in Buffalo, the US, and around the globe.

Intro  0:01 
Welcome to Buffalo HealthCast, the official health equity podcast of the University at Buffalo's School of Public Health and Health Professions. In this podcast, we cover topics related to health equity in Buffalo, the US and globally. This season, we'll take a look at food insecurity and health equity on a global scale. You'll hear from experts around the world who specialize in areas like urban agriculture and food contamination, soil science, food sovereignty, refugee health, intensive agriculture, and more. This season's episodes were completed in Dr. Kasia Kordas' Global Health Class, a graduate level course offered at the University of Buffalo, and produced by the School of Public Health and Health Professions.

Sarah Robinson  0:55 
Welcome to another episode of Buffalo HealthCast. We are your cohosts, Sarah Robinson,

Leah Bargnesi  1:01  
and Leah Bargnesi.

Sarah Robinson  1:02 
Today, we have with us three fantastic experts in the areas of food contamination, urban agriculture and food insecurity.

Leah Bargnesi  1:09 
Dr. Prathima Nalam is an Assistant Professor in the Department of Materials Design and Innovation in the University at Buffalo's School of Engineering and Applied Sciences. Her research focuses on tribology, soft mechanics, surface and interfacial forces, and atomic force microscopy.

Sarah Robinson  1:26 
We also have Dr. Anna Paltseva with us, who is currently an international urban soil scientist at the University of Louisiana at Lafayette in the School of Geosciences. Dr. Paltseva's expertise lies in urban soil contamination and remediation of urban gardens.

Leah Bargnesi  1:43 
Finally, Jeanette Koncikowski has joined us. Jeanette currently serves as Executive Director of Grassroots Gardens of Western New York. Grassroot Gardens of Western New York is a dedicated group of community gardeners and activists with the mission to share knowledge, power, and resources to grow healthy food, heal systemic harm, and strengthen neighborhood connections in Western New York through community gardens. Our three experts are all working together on a project related to soil contamination. So tell us about the project, what questions are you trying to answer? And what does this research entail? Dr. Nalam, if you want to start?

Dr. Prathima Nalam  2:15 
So, we are looking at the health of the soil, that we believe that the health of the soil is directly related to our health and only all the urban activities that we have been doing from centuries, from the time that we have started using lead paints, or we have used - or we used quite a bit of unleaded petrol and all these things. So all our activities have slowly contaminated urban soil specifically, with lots of contaminants. And there are different kinds of contaminants; organic, inorganic, and this specific project we're looking at inorganic contaminants such as lead, which is a heavy metal, and we are looking at sustainable ways to remediate them. And the concept that we are trying to use here is to get inspired from nature, which actually uses mycelium, which are nothing but the root part of mushroom. We are using that root tissue and making them into membranes, trying to remove lead from the soil. So that's the overall theme of the project.

Sarah Robinson  3:27 
That's so interesting. And the thing that we loved about this project and about why it's so unique, because you all come from such different disciplines. Can you all explain a little bit what your roles are in this project, and how you're sort of working together with your own expertise to bring it together and conduct your research. Dr. Paltseva, do you want to talk about your role a little bit?

Dr. Anna Paltseva  3:47 
Sure. I got involved in this project because originally, the researchers from University at Buffalo reached out to Dr. Howard Mielke in New Orleans, who is a well known researcher on lead poisoning in children and soil lead, and he referred the research team to me because he recently retired and I sort of inherited his lab from Tulane University. So I was really interested in this idea because I think it's so unique to use this mycelium, and it's in New York, which I have a personal connection, I used to live in New York City. So I definitely was interested to participate and get to know other researchers because this is not just, you know, typical scientists you work with. It's different expertise. And we all work on the same issue from different angles and we learn from each other. So in my role, it's mostly soil testing. I would test the soils before the treatments and we will do more in Spring and in the coming years after the treatments and actually see the efficacy, how effective the remediation is, and we will test for different soil parameters, but most important ones is to see lead concentration. So what they were before, what they were after, and eventually we'll develop recommendations for practitioners.

Sarah Robinson  5:13 
And Dr. Nalam, can you talk a little bit about your role?

Dr. Prathima Nalam  5:15 
Yeah, sure. So I come into this project as a material scientist. So we are basically looking for new materials or developing new materials that can do several - it can be from electronics to semiconductors to anything, but I was specifically interested in creating new filtration membranes to remove toxins from the environment. So it could be in water or soil. And I specifically got interested in mycelium because there is a Western New York company that works on producing mycelium materials in a very large scale. So I was wondering, why not, and they were using it for basically packaging and also for acoustic and thermal insulations and stuff like that. So my idea was that mycelium, as such we know is such a good toxin remover in nature. Can we use this dry mycelium now that it is more easily transportable, we cannot grow lye mycelium everywhere, let's say. But once you dry them out, then they're easy to package, easy to go around, and then the whole idea started that, can we now start using them as filters, and Buffalo has been the hotspot for lead. And this immediately connected us, especially when he was talking with Kasia on this. And we thought that this is something that we should address, and this went into the soil study. And we also work with Janet to do a much more broader impact of this activity. So that's how I came in.

Sarah Robinson  6:51 
Great. And then Jeanette. first off, can you tell us a little bit about Grassroot Gardens? What is it and how does it interact with the community in Buffalo?

Jeanette Koncikowski  6:59 
Sure. So Grassroots Gardens is Buffalo-Niagara's community gardening organization. We're an advocacy organization. There are - this season, this past season, there were 107 community and school gardens in our network. And we really exist to be able to advocate for the community gardens, to be able to help fund the community gardens, to help start new community gardens. So we really act as a facilitator between the community, the land, most of which is currently leased through the City of Buffalo or the City of Niagara Falls, we garden in both cities. And then, you know, really working with residents to build the gardens in their neighborhoods, in their schools in the way in which they want to manage them and run them. And Grassroots, one of the things that, you know, the community manages the day to day of the community garden, so we don't get involved in like, how was in the garden set up? Who's doing what, who's watering, who's weeding, what food are you growing, but we, because of our lease with the cities, are asked to monitor for food safety, and to make sure that the materials that are being used are safe, so that food is not contaminated. And so that is one of the many things that we do at Grassroots Gardens, is just kind of act as that facilitator and that educator around food, and things like lead contamination, because we are growing on lots that most likely have some level of lead contamination. And we've had lots in the city where, you know, you can have one right next to another and one will have heavy lead contamination, and another won't. It really depends on the very specific history of the housing that was on that vacant land. And so one of the things that we do to prevent that, obviously, like many urban gardens, is we grow above ground in raised beds, and there's always a barrier level between the ground and soil. And so we're using, you know, nonpressure-treated lumber, we're using organic soil, raising organic seed, really trying to make the food that grows as healthy as possible for the community members that are consuming it.

Sarah Robinson  8:56 
And then what about this project? How did you get involved in it?

Jeanette Koncikowski  8:59 
Yeah, so we have long been a partner with the University at Buffalo School of Public Health, and already had some connections to various partners there, and I believe when Dr. Kordas approached us, it was through a referral from Dr. Samina Raja at the UB Food Lab, who was also a primary partner of ours. And Dr. Raja and her students have been a longtime evaluator of Grassroots Gardens. And so we were all kind of connected and found out about their interest in studying lead in the soil and one of the things that, you know, and then the remediation through the mycelium, which is really cool, because what better way to deal with contamination than through nature? And one of the things that I was really personally excited about as an alumni of the University is that UB has a commitment to applied research and so not just doing research for the sake of doing research, but research to improve people's lives, research to make sure that there is an impact in the community. And so we were approached about partnering with them, and kind of just first as a, you know, a way to learn for the researchers involved, to learn about kind of boots on the ground, what happens in terms of gardening and urban ag around soil? And what are some of our gardeners' concerns about the soil? And then from there, we really were able to kind of grow a plan to add a public education component to this project. And so there is the research project, and then there is also the opportunity to use the research project to educate the community about everything from, you know, just safe urban gardening practices, to how does lead get in the soil, to what is the possibilities for remediation?

Sarah Robinson  10:37 
Dr. Paltseva, so you've done a lot of research about lead and soil. Can you tell us about what effects lead exposure actually has on human health? And how common are these exposures? How concerned should we be about them, especially in an urban setting? And how are we seeing the effects of them today?

Dr. Anna Paltseva  10:54 
Definitely lead exposure has been drastically decreased since 20th century, when it was really serious issues and lead was everywhere, in the gasoline and lead paint, but the legacy of that deposition in the air or new soil is still present. So what used to be emitted into the air or painted on the walls is now going down to the soil. And this is why partially Buffalo has such issues, or any other big cities in the US or in the world. So it's really, there is a relationship between the size of the city and how much industry was there, roads, and of course, you know, how many people live there in older buildings or buildings that are painted with lead, before 1978, and if those homes were remediated after this or not. Were they repainted or was any cleanup done? The dust that falls off this paint gets to the soil. And when children play in the soil, they inhale it or maybe ingest it through their fingers. And this is where the biggest problem lies, it's mostly for children. Kids are way more susceptible to lead poisoning than adults. Adults, of course, can still get exposed, but it's maybe more through their occupations. And if they are, you know, working in the condition when they do not protect themselves, or they don't know about the contamination and they're working in those fields. But in most cities, we're really concerned about children and the playground areas or gardens, backyard gardens versus public places, and previous research in New York City show that the private yards, backyards, have more contamination of lead than public areas. Because in public areas, different organizations, nonprofit organizations, Department of Parks and Recreation, they constantly change soil, the lawn, maybe they add mulch, compost or do some sort of introduction of a new material. And it helps to bring down the previous contamination to very low levels. But in private yards, people very often don't know, especially if it's a new buyer, and they don't know anything about the land history of this home or overall about the neighborhood. And they have little children. So one of the things is really to learn what was done before in this plot, and test and then we'll find the recommendations for the families, what would be the best solution for them. But it's really a big problem. It's everywhere. The homeowner can become researchers, by, like, studying the history of the lot and simply send the samples to the labs and see what it is because as Jeanette was saying, one plot can be different from another plot. And it's really hard to know unless you do a little bit of investigation. Very often the inner cities, inner part of the cities like downtowns, or where the industries were, you would find and have high concentrations and when it gets closer to suburbs, you will see less contamination. It's a very typical pattern for big cities. So it's high in inner cities and drops close to outskirts.

Leah Bargnesi  14:18 
Dr. Paltseva, can you explain what bioavailability is? And if that is something that heightens contamination from produce that's grown in urban farming?

Dr. Anna Paltseva  14:30 
Good question. So bioavailability is really a fraction of toxins in metal, in our case it's lead, that can harm a human body, or even a plant depending how you define bioavailability. Some researchers refer to humans and plants. Some say phyto-availability for plants and bioavailability for animals. In simple words, it's the fraction that can be toxic for humans and bioavailability of lead, specifically, will be determined by different phases or different chemical presence of this metal, like what form will lead exist in. If it's a lead carbonate or lead oxide, it may be much easier to dissolve, can be uptaken by humans much easier. But if it's lead sulfites or phosphates or combined with organic matter, it will be less bioavailable. When we test soil, we typically test for total concentrations, and it gives us the overall all forms of lead. We don't know if it's oxides, carbonates, phosphates or anything else. But when we study bioavailability, it suggests what is the harmful portion of this total availability, total concentration. And it's, we don't always seek a relation between bioavailability and total concentrations, because again, you may have very high concentrations, total concentrations in the soil. But maybe it exists in the lead phosphate form. And the bioavailability is very low, and people will not be exposed to it, like so it gets to the human body, it does not dissolve very easily, lead from phosphates, and it just goes through the human body, and that's it. But if it's another more diluted or soluble form, then it can be transferred in the body in the blood for like 28 days and then goes to bones and goes to brain if there is not enough calcium. If the calcium was present, especially in children, then again, it may not be taken up by bones and goes through the human body. So what we really want to ideally study is bioavailability of metals in the soil. But there is a trick to it, because it's hard to study. Bioavailability is typically studied on the animal trials. So it's when they take contaminated soil and feed it to an animal. And then they have to test the urine, blood, kidney and see what the uptake is. It's unethical, time consuming, very expensive. So scientists came up with different alternative methods. And that was my research, it was based in New York, is to study the bioaccessibility, which is done in the lab. And it's a proxy for bioavailability. When we create solutions that mimic gastric system at different pH, and we basically do extractions of lead, mimicking or simulating what could be done in a human stomach, there are also limitations to those methods as well, we do the best we can. But it's really, if people can invest and send it to a lab, there are only several labs in the country, I think that offer this to people, but do some bio accessibility tests, it would be good to know not just the low concentrations, but also what is the harmful portion of it. And that's what basically bioavailability or accessibility is - the harmful portion toxic for people. But plants have different response to contamination as well. It depends what type of plants not just because it's lead or arsenic or cadmium is in the soil, doesn't mean that we will transport into the food because it will depend on the type of the plant. Fruit vegetables like tomatoes, eggplants, squash that grow further from the soil and have the tall - they have physiological barriers inside of the plants. So it prevents from contaminant to go into the fruit. But if its root vegetables, they have very weak physiological barriers, and there is a high chance of uptake into the root vegetable. And then there are also leafy greens and herbs. They can also get contamination but from a different mechanism. It's through splashes from surrounding areas. It's not necessarily uptake, it's really because they're short planes, and they get dust deposits from, like, after rain or during rain. So it's just adhesion, it's very hard to wash off particles that's on the surface. Washing helps, but doesn't completely wash off contaminants. So this bioavailability for plants or food production will be different depending on the plant type and also how far it grows from contaminated soil.

Leah Bargnesi  19:26 
Thank you. So on that note, Jeanette, can you speak more on if contamination and pollution have been an issue with the food produced your community gardens? And if so, how have these issues been solved?

Jeanette Koncikowski  19:38 
Yes, so every urban garden in any city anywhere around the country, or around the globe really needs to be concerned about lead in the soil while we are bringing in imported soil, meaning we're purchasing clean, tested, lead-free soil. In our case, we get organic soil from a vendor that is able to deliver to both cities where we have our gardens, you know, we know that the soil that is coming in is clean. The question remains, you know, as Dr. Paltseva just said about the contamination from the lot itself, so the ground soil that is there that you're walking on, you know, when there's rain, are you kicking that up? If it's a dry, dusty day, are you kicking that lead up? And is that getting into the soils? So we actually changed our, you know, over the years, as we've learned more and more about soil contamination and how to prevent it, we have changed the size of our raised beds, you know, originally they were six inches, now they are 12 inches minimum, we recommend 18 inches as our kind of gold standard for trying to just raise up the height of the beds. And this, you know, there's no way to 100% prevent contamination, or to even necessarily test all the gardens, you know, we have 107 gardens. So while we do soil testing, we tried to test at least five gardens a year both for the ground soil and the soil inside the beds, as part of our commitment to soil safety. And we are part of the Greater Buffalo Urban Growers. We are the only non-farm partners. So it's mostly urban farmers, and they have, locally, a pledge to save soils and to soil testing. And so as part of our commitment to being in that coalition, we do try to test at least five gardens a year. We have some gardens, some of our oldest gardens, a handful that are able to grow safely in ground because they have done years and years of extensive soil remediation, and we've been able to test that soil over the years to see that their lot soil is clean. We had one garden that's in phytoremediation with sunflowers for three years before they planted and that successfully cleaned the contamination that was in the soil, so it can be done. But as kind of a default, we have to have everyone grow in materials that we provide. So Grassroots Gardens has a preferred lumber provider, we don't want, you know, a lot of people we understand, obviously, with a focus on recycling want to do things like, why can't I just recycle a pallet that I have and make that a raised bed? Well, if you're growing food, that pallet can also have contamination. And so, you know, from chemicals, and we don't want that then getting into your foods. So we try to provide all the materials that a community garden needs to get growing safely. And then we also provide that education. So a lot of our gardeners, you know, everyone wants to get their hands in the dirt. And that's beautiful. And it's a great feeling. And you need to have gloves on to do that safely. Right. And you need to be able to wash your hands as soon as you leave the garden. You need to be able to, if you're coming home, you know, I have a rule in my house because I work in gardens all day long: nobody wears their shoes in the house. They get left outside on the stoop so that we're not tracking, you know, that potential lead from a lot into our home and then getting contaminated with it that way. So I think a lot of it is just public education. We work with a lot of community members that are new to Buffalo, and are not aware of the city's industrial past, are not aware that a lot of the vacant land that their current house was built on may have had a house demolished in the past that probably had lead paint that got into the soil. And so we definitely see, you know, Buffalo has high lead tracks in certain zip codes, where we know there's even greater contamination and for our gardens in those neighborhoods, we are especially focused on community education to let people know. We also have a fiscally sponsored project called Buffalo Freedom Gardens that started during COVID as a rapid response to COVID and builds residential gardens in people's homes. And as we have sold through that project, we provide a raised bed to a family, we provide the safe soil, we provide the seeds and the seedlings. Buffalo Freedom Gardens, Ms. Gail Wells, who runs that, has been a longtime Grassroots Gardener does all of that. We help fund it and get the supplies purchased for her and help distribute them. And one of the things we've noticed in going into people's homes and in their backyards and front yards, you know, everybody that's a gardener wants to show off the garden they have, if they've done it before, we do see a lot of people both that are new Americans and that are native Buffalonians that are growing in their backyards or front yards because they need food. And so that's always also an opportunity to make sure people know why the raised bed is important. Where they can access additional funding for raised beds or how they can build them more affordably so that they have a chance to learn about, you know, are you aware that there might be lead in that soil? Have you had your children tested for lead? Is that something your family's concerned about? And sometimes we will hear about people's stories that oh, this person did did have high lead testing when they were two. And so we just want to encourage people as we're meeting them and talking about gardening and soil safety, find healthier ways to do it. And there's often you know, a financial cost to that. And that's one of the things that Buffalo Freedom Gardens and Grassroots Gardens tries to do is we don't want there to be a financial burden for people to be healthy and to be able to grow food free of charge. We believe food is a human right, and there shouldn't be a cost to it and everyone should be able to grow Food as they need to. And in order to do that, you have to have lumber that can run, you know, if you're buying cedar lumber, it can run $250 right now for a four by eight bed, then you're adding organic soil, the cost of organic seeds, it can get very expensive very quickly to grow the healthiest possible, even when you're putting in your own labor. So we really try to work with the community not just to provide the education, but to provide those materials so that people can grow in the ways they want to at home and grow foods that are important to them.

Sarah Robinson  25:23 
That's so interesting. I grew up in the suburbs. And this isn't anything that I've ever thought about, like the importance of raised soil beds, not something I've ever ever thought about. So are all the gardens for Grassroots Gardens at least, they're required to be raised soil beds, or do you just test the soil in areas where it's not, they are. All right.

Jeanette Koncikowski  25:47 
So all new gardens have to use either mounded, meaning they have to have, you know, an 18 inch mound of soil, which like if they're growing a fruit tree, for example, we know that fruit trees tend to not take up lead into the fruit very often. But in that case, it still has to be a mound of soil just for kind of like added safety, or we're giving them lumber for the raised beds. We have started in some of the gardens switching to different kinds of metal containers, stainless steel, things like that, that we've been testing. But almost all of our gardens, you'll see four by eight, four by four raised bed lumber beds. And then there are just a handful of gardens that have been around, our garden network this year, our oldest gardens are 30 years old, and the organization is 27. The gardens actually predate the start of the organization. So for some of our oldest gardens, where they have been composting for 30 years, that soil has been tested and has been found to be clean. But even there, most of the gardeners are still choosing raised beds because it makes our lives easier. Right. Permaculture is a great way to garden, but it also means you're getting down into the ground. And we have a lot of seniors that garden with us that that's just really not an option for them anymore. So we've been more and more trying to raise and receive funding to do elevated raised beds that are actually, you know, four feet off the ground. One, it's better for the soil contamination because there's less chance of the dust coming up for feet. And then two, for accessibility purposes. They're easier to work with.

Sarah Robinson  27:15 
All right, great. Thank you. So interesting. Never ever thought about that. All right. And so Dr. Nalam, for the study that you're all collaborating on, mycelium is used to remediate lead in Buffalo soils. Can you tell us a little bit about what mycelium is and what your findings are?

Dr. Prathima Nalam  27:31 
Yes, so mycelium is the root part of mushroom, whatever mushrooms that we see when we're walking in the woods are actually the fruiting bodies, that's just probably 1,000,000th of the entire plant that is inside a fungus that is inside the inside the soil. And fungal networks are known to spread as the neurons spread in our brain, so they're all interconnected and criss crossed. And they have a lot of symbiosis effect with all the plants, microorganisms that are there in the surroundings. So they are known best for absorbing anything that's surrounding them. If it's dead creatures or toxin materials or nutrients, they tend to assimilate them and then kind of remediate them from that environment in this process. They can also sense sort of chemical gradients within the soil. And if there is someplace where they need more nutrients or if there is a need for nourishment, they can actually transport nutrients to make things more homogeneous in the entire network. So we already know that lye mycelium, lye fungi are very good toxin removers. But as I said, not everyone can grow mushrooms in their backyard, especially in Buffalo, half of the time, it's cold and we need usually damp, dark conditions to grow mushrooms. So this, even though it's such a sustainable option, and a cheap option and an environmentally friendly option, it's just that not everyone is exploring growing mushrooms first and then mushrooms are very choosy, where they want to grow and how much they want to grow. So this actually led us to thinking that can we now actually make materials out of them, like a biomaterial out of them, so that we can easily transport and move them anywhere we want. Let's say, like Jeanette said, we have these raised beds or we have our own backyard soil. So can we insert these sheets of mycelium in these beds or in topsoil and then insert into the topsoil and then leave it for some time so that the mycelium does the whole detracting the lead from the soil and then later on we carefully remove it out and then we dispose it. We dispose it off in such a way we could use our own backyard soil for growing vegetables and stuff. So this brought us many fundamental questions. So though, there has been research on how mycelium assimilates all these heavy metals, it basically works with lots of proteins that are there on its cell wall, it works with lots of enzymes that it kind of generates. And they basically and endocytosis means like, they kind of eat it literally, eat it into themselves and the cell, inside the cell, they get disintegrated. So, but it's no longer alive, when we are drying it, when I say dry, it means we literally bake them to a very high temperature around 80 degrees and above. And so the all the live cells are dead, but what stays behind is the rich network of proteins on the top of these fibers, and those contribute to a lot of absorption of these lead ions from their environment, whether it's from water, whether it's from soil, they can absorb the lead, and they can - it's kind of you sticking them, kind of a thing. So, the question was, are these proteins still are active to do such a process once they are dried? And if so, what is the efficiency for them to do it? And can we do something or can we now even now modify or treat these membranes such that we can actually convert this lead into forms like what Anna just said, into like phosphates or stuff like that, so that we reduced the bioavailability to the animals and stuff like that. So, these were fundamental research questions that we wanted to ask even before we deploy them in the soil. And in that process, we have been trying to play around understanding what kind of proteins are still there and what was the capacity of absorption and we also now started treating other membranes with the phosphate solutions and then expose it to lead and we got more than 90 to 95% of remediation of lead from a solution, but that means a water based system. And what we also did is also a big factor that play a role is the concentration of the light, like Anna said, there are - there can be different concentrations of lead depending upon where the lot is and then what was the prehistory of the lot is and also, and each soil have their own pH of the soil, and they all impact how efficiently these proteins will now interact with the lead. So, we wanted to understand all these parameters systematically in laboratory conditions to know that what involved mechanisms really involve and which of the mechanisms have the most remediation efficiencies. So, once we identify them, then we can use those treated membranes and then can start deploying them into the soil and see that how effective we are in the soil. So, this is where we are currently also in the project that we finished our initial studies in the laboratory studies and we have identified two mechanisms and as I said, one mechanism is bioabsorption. So individual lead ion if it is available, they could come and directly attached to these proteins, but we also add the specific metals, specific compounds like phosphate, which we usually add anyway, so you know what nutrients, so phosphate is not something you're adding out of ordinary or something. So these phosphates end up making crystallize of lead so we can get phosphates and lead carbonate crystals. And now we are trapping those crystals onto this membrane. And then this way, in both these processes, we saw that if we combine them we get the highest efficiency of remediation.

Leah Bargnesi  34:02 
That's really amazing. Can you, Dr. Nalam, I know that you use microscopy imaging, can you explain what that is and how it's used in this study?

Dr. Prathima Nalam  34:10 
Yes. So, we use scanning electron microscopy, which is, if you know the regular optical microscope, you're shining through light to do that, and then you see any features that you want to see, but these fibers, the mycelium fibers are as thin as your hair or even thinner than that. So, if you want to see what kind of interactions are happening and how is lead getting deposited on them, you no longer can use optical microscopes. So we actually use this more high resolution microscope called scanning electron microscope where instead of light, we now bombard the sample with electrons, beam of electrons, and that helps us to give a very high resolution image of the mycelium and we try to see the images with just pure, as I said, bio adsorption where we don't add any other additional phosphate or when we add phosphate we see this crystal growth happening. So, we can understand at what concentrations how much crystal growth is occurring, what are the rates of these crystal growth and also what is the percentage of the mycelium is getting covered with lead. So, we can map all those things, which can all help us to determine the efficiency the performance of a specific mechanism that we are trying to look at.

Leah Bargnesi  35:34 
And I know Dr. Nalam, you spoke on this a little bit already but is there a possibility for mycelium to be used to remediate other heavy metals that usually found in urban soils?

Dr. Prathima Nalam  35:45 
Yes, definitely. There are many inorganic compounds like arsenic, mercury, cobalt, they have come from different sources, different industrial sources, they all got accumulated in the soil. And they again, every of these heavy metals will have their own compounds because they don't stay as just metal ions by themselves. So they make these compounds. And the mechanisms will be more or less the same as we are studying for the lead so they could be easily extrapolated to the other heavy metals. And we believe that this tri mycelium would still have very high efficiency to remediate other heavy metals from the soil. What is more interesting is also that not just heavy metals, but mycelium is also very, can has a nature to absorb organic matter. And that's not the property of every filtrate that's there on the market. Usually, most of the filters that are there are polymeric synthetic materials. But Mycelium is in such a way that it can, its proteins are in such a way that it can absorb not only just heavy metals, but also organics and peat mosses are one of the more concerning issues currently that EPA is looking at. The mycelium is also a - it could be one of the membrane that can remove this. And that should be an interesting study to carry out.

Sarah Robinson  36:00
All right, great, thank you. We're gonna skip ahead a little bit and lean into the policy side a little bit, because we talked so much about all the great science that you're doing. So how does this translate into policy? How do you have to collaborate with government or other organizations in order to get your research heard and seen and for action to be taking? Dr. Paltseva, do you want to talk a little bit about this? Have you had success with this?

Dr. Anna Paltseva  37:43 
Well, I worked a little bit less with the policymakers than other researchers. And I think in this project, it was mostly others like Kasia and Olga and Prathima, who did a lot of work in the collaboration, like we're actually creating collaborations and work with the City of Buffalo. So I've kind of stayed away from it, because that kind of not exactly my area of expertise. But I definitely enjoy being on meetings where we have different organizations, not just the scientists, but you know, the city, the nonprofit organizations, and, you know, garden representatives, because you can actually learn what it takes to get your result to the policy and what they're looking for, what they're looking at when they evaluate science results. So it definitely benefits me as a researcher to see how it works. But I kind of was shielded from figuring out the logistics behind it by some senior colleagues.

Jeanette Koncikowski  38:47 
I think there's definitely been success, you know, Grassroots Gardens, before I was involved in it back in like 2012, 2013, were invited by the City of Buffalo to participate in the Green Code that was made and it's really one of the most successful green codes in the country. And the City of Buffalo does have a role in this grant as a key partner in it. And so they have been very supportive, and I think very interested in, you know, the potential for this technology and really at the forefront of wanting to figure out this, I mean, the industrial pollution in Buffalo in the legacy contamination has been an albatross around the neck of everyone that lives in the city, in the city government, it's, you know, would be millions and millions and millions of dollars to remediate every lot here. And so they have a vested interest both financially but I think ethically too, in determining, you know, what are better ways to do this. And again, I kept coming back to like, what was so exciting to me about this project was you're using a natural substance straight from Mother Earth to clean the damage that humans have done to the earth and so, you know, to kind of be able to come full circle like that and find the the answer right in nature is, you know, one way we might be able to better clean up the kind of mess that we've collectively made as humans to the land. So I do think they're listening. And I think there is great potential in this in terms of policy. And we have another partner on the grant, Dr. Emanuel Frimpong, and he is the evaluator on it. And he's looking at not just kind of the implications for policy in terms of the land contamination, but policy for, you know, how we support and educate and implement education in the community around soil safety.

Sarah Robinson  38:51
All right. And then I know you touched on this a little bit, Jeanette, but what can farmers do to, especially urban farmers, do to keep themselves safe, as this potential new program is being rolled out?

Jeanette Koncikowski  40:48
Yeah, so one of the things that we were really interested in and were able to get the funding from HUD on this grant to do was to revise a project we have called Safe Roots. And that is our public education campaign on soil safety. Way back in 2013-14, we had some funding to offer the creation of Safe Roots guidebooks, and Safe Roots workshops that worked primarily at that time in the new American communities. We were able to get the guide translated, and to provide our growers in urban areas, whether they're farmers or gardeners with information on how to keep yourself and your family safe while you're growing in a city. So the funding in this project is also supporting kind of our revision of that, because it's been 10 years almost. And it's time to, you know, update it all. And so we also have been working with our partners at the Western York Children's Environmental Health Center to update the guidebooks, they're going to be published in nine languages. You know, we have a burgeoning new American population in the city of Buffalo, which is why our census data has gone up for the first time in 40 or 50 years. And we have people that are interested, that have come from agricultural backgrounds, that want to be urban farmers here. And so, you know, through groups like the Greater Buffalo Urban Growers, connecting them, to coalition groups of farmers and growers that are well versed in, you know, how to grow safely in the city, I think, again, you know, just at a very individual level, it's about protecting equipment, it's about hand washing, and vegetable washing, and making sure that, you know, every step of the way from the first time you walk on the soil until you leave the soil and getting, you know, leaving your clothes out and getting them washed appropriately. And there's so many steps you can take, and we really try to lay out in the guidebook, what that looks like. So if you are, you know, visiting any of the urban farms in Buffalo, you'll often see that most of them, again, unless they have been well established and well composted, and well able to remediate the soil, are growing raised beds, they will bring in outside soil. And then they also, you know, we provide education on things like how to gather rain safely. People assume, you know, if I gather the rain, I can use it in my garden. Well, it depends on how you're collecting. And if it's coming off your asphalt shingled roof, it is not safe, because of the contamination from the shingles. And so, you know, we encourage rainwater harvesting, but not using it for food production and food watering. And so, you know, those are all things that have to be considered along the kind of growth cycle of the garden itself or the farm. And obviously, farming is at a larger level than we're doing at Grassroots Gardens. You know, we are kind of, we consider ourselves at a neighborhood scale, and not at an urban farm scale of growing. But a lot of the same principles apply for soil safety. And so those guide books should be being released before the spring, we are working with partners at International Institute right now, and wonderful a graphic designer, Rachel Bridges, who I'd like to give a shout out to, who's helped us really bring the look of the guidebooks into the 2020s. And so those will be going into final production in the next couple of weeks, and we'll be able to share them out for free with the public, hopefully by Spring 2023.

Sarah Robinson  44:08 
That's so exciting. And we'll definitely share the guidebook with the episode release so that more people are able to see it. That's so cool.

Leah Bargnesi  44:15 
Yeah, I was just gonna say that that's awesome.

Sarah Robinson  44:18 
And I would also pose this question to all of you. What is the single greatest thing and the most important thing that we can do to protect human health when it comes to urban agriculture and contamination?

Dr. Anna Paltseva  44:30 
I think what first comes to my mind is to spread more information and you're doing part of it, you know, through modern technologies and social media outlets. So thank you for you doing this podcast and spreading the word on science. And I think that's - just do more for public outreach and education and work with partners outside of academia, bringing science to people in their most digestible way and what Jeanette described is just perfect. That's what we need more of in every city.

Jeanette Koncikowski  45:00 
Yeah, I think I would just encourage people, you know, we've been talking about contamination and the fear around it right like, am I going to grow food and hurt my family? And there's research study after research study after study that shows the benefits of growing food at home far outweigh the risk of the contamination, you do need to be aware of it, you need to do things to minimize it. But in no way want anyone to leave here thinking like it's not safe to grow food in a city - it very much is. And we hope to be a resource, not just for community gardeners, we have a ton of resources on the grassrootsgardens.org website. And you can go there as a home gardener and learn a lot about how to grow your garden at home safely in the city. So really just want to encourage people to lean into gardening, see it as the gift that it is, and know that there are organizations like Grassroots that can support you whether you have a financial burden to getting safe materials for growing or whether you need that education. And even better, if you want to join community gardens so you don't have to grow alone, and you can get to meet your neighbors and come and enjoy the kind of garden party that we have. When we're growing together, it's a lot of fun. And, you know, the community of gardeners in Buffalo is just an amazing, fantastic resource too, so I would put a plug in to keep growing and don't let it stop you from from being able to grow.

Dr. Prathima Nalam  46:19 
So, I would just conclude by saying the soil, the current rate at which it is deteriorating. There is a literal unavailability of soil for growing food. We already have food scarcity, and 20 to 40 years from now, we will no longer have agricultural soil to meet like probably 9 billion, probably, of population to come soon. So urban gardening, it will be one of the key ways to go about it. And one thing that has also been the key factor of our project is public awareness, that this needs to be known that there are contaminants and the way they get contaminated and how can you remediate them is very, very critical. And also that all citizens need to start deciding or insisting on policymaking for these tools so that this gets included in our agendas at the highest level, to the most household level, so that we can act now, only if you can act now, then we probably we can the next 20-30 years are very, very critical for us to to bring back Mother Earth's soil to us back. So I feel that's that's the need of the hour, as important as climate change I might want to put it there.

Sarah Robinson  47:47 
And no better team to tackle it than you three, I would say. All right, is there anything else that you want to add or plug or shout out before we end?

Dr. Anna Paltseva  47:58 
If anyone wants to test soil, they can send it to Louisiana at Delta Urban Soils Lab, and we accept samples from all over the country.

Sarah Robinson  48:06
We really can't thank you enough for being here. Thank you so much for taking the time to speak with us today.

Outro  48:12
This has been another episode of Buffalo HealthCast. Thank you to our guests, Dr. Prathima Nalam, Dr. Anna Paltseva, and Jeanette Koncikowski. Omar Brown is our sound editor. And our theme music was written and recorded by Sungmin Shin of the UB Music Department. This episode was written and recorded by Sarah Robinson, Leah Bargnesi, and Sib Banuna for Dr. Kasia Kordas' Global Health class in Fall of 2022. I'm Sarah Robinson, your production assistant. Join us next time on Buffalo HealthCast to learn more about health equity in Buffalo, New York, the US, and around the globe.

Nicole Klem  0:04 
Hi everyone and welcome to another episode of the Buffalo HealthCast, the University at Buffalo's premier health podcast. I'm your host today, Nicole Klem, a Registered Dietitian and Director of the Clinical Nutrition Graduate Program in the school. And with us today is Catherine Brown, a Registered Dietitian and owner of Inclusive Nutrition Counseling, a nutrition counseling practice. Her model focuses on individuals with mental health issues and disabilities. She's working on weight bias in health care, and is focused on a Health at Every Size approach to help clients make and achieve small goals toward overall health success. Thank you so much for taking the time to speak with us today. So I'll begin by asking you to tell me about yourself. And tell me about your practice model and how it's unique.

Katie Brown  0:46 
Thank you for having me. Like you said, my practice is focused a lot on mental health, and on treating people with disabilities. My goal is to create somewhere where people could feel safe, who typically don't feel safe in normal health care settings, they feel like doctors don't listen to them or just blame either their mental health or their weight for whatever medical issue they're having. And, you know, don't really have the patience to help them work through changes that they need to make to improve their health and quality of life. I like to focus a lot on obviously, small changes, like you said, but also really focusing on the patient and how their life is and how we can find changes that will work for them. Because you know, overhauling their whole diet or making a bunch of changes isn't always very realistic for someone that's already struggling with a lot of things. But that also doesn't mean that there's nothing we can't do to make their situation better and make them healthier.

Nicole Klem  1:40 
And what drew you to this type of practice?

Katie Brown  1:42 
So I am a patient myself. And I've spent a really long amount of time at doctor's offices, meeting with doctors. And one of my doctors, this was probably five or six years ago, I came in with a variety of complaints. And she told me that it was psychosomatic and that there was nothing wrong with me. And I would never get better. And it was really difficult for me. And I actually avoided doctors for two years after that. And then I finally got diagnosed with lupus. So it was not psychosomatic. And I definitely know a lot of other people out there experienced similar things and really want somewhere where they feel safe, and they feel heard and they can get the help that they need. And so that's kind of where I wanted to create something because I wanted to be a space where people weren't afraid to come see the doctor or the dietician, and they felt like they could be open about their challenges and not be judged. And I think that's really the start to really changing overall. Because you know, if they're not going to be open with their provider, because they're too afraid of being judged, then you can't really help them.

Nicole Klem  2:44 
Yeah, all right, interesting. Definitely a little area of dietetics that is important in different populations. How does your practice work to minimize weight stigma, specifically, in nutrition counseling?

Katie Brown  2:56 
Obviously, I'm just gonna go over what weight stigma is, but it's basically this bias towards the fact that weight is, you know, the root cause of a lot of issues. And that is what needs to be addressed. And a lot of doctors when you come in for like knee pain, back pain, even depression, they'll be like, Well, have you tried losing weight. And for a lot of patients, one thing is weight loss is not really achievable. And, you know, we want it to be we want it to be like calories in calories out, oh, you're just gonna reduce what you eat, and you're gonna lose weight. But for a lot of people, it's really, really difficult. And the second thing is that some people have lost weight, you know, like, maybe they were 300 pounds. Now they're 200 pounds, and the doctor is like, well, you just need to lose weight. It's like, I lost 100 pounds, which was really difficult, expecting them to lose more is not really realistic. And the truth is that there's no condition that only obese people get. Every condition that obese people get, skinny people get to. And so we have to realize that like, while it might be a contributing factor, usually there's still other stuff going on. And there's usually other treatments. And that's one thing for me is, you know, I was really pushed to lose weight to get better. But as I met more people, there's a lot of people with autoimmune diseases who are very thin, and they still have joint pain, and they still have all of the symptoms I have. And so realizing that maybe it's not weight, and then being able to make changes and feeling better, even without weight loss. So sometimes, you know, we think, well, if you're eating healthier, you must be losing weight. But that's not necessarily the case. You can eat healthier and be maintaining weight and feeling better, and having better cholesterol and better blood pressure and all those things.

Nicole Klem  4:30 
In the counseling settings, what tools are you using to, you know, make the patient either feel more comfortable with their experiences of the past in health care or combat some of the stigma they might be coming to you with?

Katie Brown  4:45 
So I would say my patients actually talk the majority of the sessions, especially for the initial one, and we really go through a lot of different things like what diets have they had done before? You know, how do they feel about certain things? How do they feel about their weight? What has their doctor told them? What are their goals because some people are still kind of interested in losing weight. And, you know, they're like, hey, if I lose a little bit of weight, great, but I don't want to, you know, lose a ton of weight, I don't think that's realistic, which is awesome. There are other people that are like, I don't want to lose weight, I don't think it's realistic. And I have a history of eating disorders. So it could be dangerous. For me, I think actually, the first thing that's helpful is that I am also overweight, there's a lot of people in the weight-inclusive space who are very thin, it's actually a trope of really thin dieticians, who are like, weight-inclusivity, it's great. And it's awesome to have lots of different people have championing it, but they don't really understand what it's like. So I think that's really helpful. And then just really listening to them, listening to their history, what their concerns are, we actually talk a lot about educating. So you know, they'll think, well, I have to lose weight in order to improve my cholesterol. That's what my doctor said. And we actually talk about what is the science behind that? What do you actually need to do to be healthy, and it kind of makes them feel better, that they don't necessarily have to lose weight to improve their health.

Nicole Klem  6:06 
And so if folks maybe haven't always felt heard, and part of your goal really is just to listen to some of their story.

Katie Brown  6:14 
Yeah, and validate their feelings, because a lot of them feel like, this is really hard, why can't I be successful. And then, as I talk with them, you know, explaining, you're not the only one that's not successful. 99% of diets fail, most people regain the weight. And so it's not unusual that you have those struggles. But also, that doesn't mean you should give up, and that there's nothing you can do.

Nicole Klem  6:38 
Sure, I'd be curious to learn a little bit more about the accessibility of nutrition counseling in general, you know, so again, people might be uncomfortable in the health care system, but still know that they're, you know, seeking some nutrition changes. Is it something that is affordable that all groups have access to? Or are we seeing some gaps in who can receive nutrition counseling, and who has, you know, access to it or, you know, understand how to seek out someone like you. So here you are providing an excellent service for people who may have been, you know, feel like they've been harmed by the health care system, or the stigma or bias out there, but how do they get to you, or gaps that are in sort of access to nutrition counseling?

Katie Brown  7:23 
There's a lot. This could be a long discussion. I would say one thing is that doctors and patients don't always know we exist and what we can do. And so people don't realize we can help with mental health, and we can help with a variety of different conditions. And they kind of think, Oh, you just do diabetes and heart disease, and I don't have those, so I don't need to see you. So I'd say the first thing is having people realize that nutrition can affect a lot of conditions, actually, the majority of them. The second part to that is there's a lot of issues with insurance coverage. So some insurances are great. They cover so much nutrition counseling, and actually most commercial insurances cover a huge amount of nutrition counseling, it has no copay, because it's under preventative, usually there's no cap to the number of times they can see you. So if they need to see you every week, they can see you every week. The issue is Medicare only covers diabetes and kidney disease. And they will cap you at two to three hours per year. So basically, you know, if you have any other issues, and you're on Medicare, we can't help you. And this is really hard, because there's people who when they go on disability, they end up on Medicare, Medicaid, if they're permanently disabled. And Medicaid does not cover any nutrition counseling. And Medicare obviously only covers those two. So if people are, let's say they're underweight, they're actually malnourished. You know, I've had patients where they can't absorb nutrients properly. She was becoming severely malnourished because she couldn't absorb nutrients properly. She's like, I'm worried that I'm going to die if I don't fix this, but she's on Medicaid, and it's not covered. And so then you get stuck with like, do you take these patients pro bono because they don't have money to pay you? Or do you, you know, send them away. And this definitely becomes really challenging and very hard because you want to be able to help everyone but also you can't have an all pro bono company. So I know a lot of dieticians, who will have several pro bono spots in their schedule. So like, they'll say, like, okay, I'm currently going to work with 2 pro bono patients. And then when those ones leave, they then will see another one. But obviously, it's not a large majority of your practice. There's currently a bill to expand Medicare coverage for M&T. And then in Medicaid for New York State, they've expanded it to pregnant women and infants, I believe. So we are getting there and it's likely that the Medicare bill will pass and hopefully it does because then it will expand to so many more areas. It probably will still have the two hour limit, which I think is not enough for a lot of conditions and a lot of people but at least they will be able to get something because right now they can't get anything

Nicole Klem  10:00 
And how about the delivery of services? Do you do a lot of telehealth? Are you more virtual? Do you see people more in person? You know, one of the barriers, I think is time and transportation and, you know, scheduling an appointment that might be in a different location than they're used to going.

Katie Brown  10:18 
What's really interesting is that for some people, in-person is more accessible. They feel like they struggle with technology, especially older people, or you know, they have hearing problems, they can't hear as well, all of those things. So they like in-person. And then other people prefer telehealth because it's much easier for them based on their needs. I have a patient with six spinal fusions, and she has to spend a lot of time laying down. And so I'm able to see her, she uses her phone, and I actually see her from her bed, and we're able to, you know, talk and provide the care that she needs. I also see patients in other states. So I'm very niche in what I do, and I will have patients who, maybe they have diabetes, but they also have a history of eating disorders, and they need to treat their diabetes in a way that isn't going to trigger their eating disorder or their mental health. And so then they'll come see me, and I actually love it. I have a lot of patients in Washington and California, and it's awesome to be able to have really good provider/client fits because of that.

Nicole Klem  11:17 
I think of folks in rural areas that might not have a private practice dietitian, you know, within 15-20 minutes the way we might have in Western New York, you know. I'm sure Washington and Oregon, you know, could be fairly rural areas, and how do we provide services to those folks as well. And so you had mentioned your patient with some of the spinal fusions? Do folks with disabilities experience more food insecurity? And are they maybe more underserved by the health care system or by dieticians?

Katie Brown  11:48 
A couple of things. So actually going back to that patient for a second, she is on Medicare, which isn't covered as we talked about. And so luckily, she actually lives with her parents at home because of her disability. And her parents were able to pay for her to get nutrition counseling, but if it wasn't for that, she wouldn't be able to access it. And because of the support system, she is able to, you know, get food, her parents help her make food, all of those things. But there are other patients who are actually pro bono who are on Medicaid, where they just get food stamps. And in addition to food stamps, I think they get $1,000 a month. And you know, they live in a really expensive area, they live in the Portland area. And so most of their money goes to rent, they don't have extra money to go towards food. So they have to live on food stamps, and the amount food stamps give you is very low. And what's actually interesting is there was just this kind of like viral thing going on about the Thrifty Food Plan. Have you heard of it? Yeah, so the USDA has this plan. And they're like, this is what cost conscious people should eat that is affordable. And so food stamps are based on this. So basically, they take food stamps, and they're like, Oh, well, you know, you can buy these foods, you're fine, you have enough money, but it is totally unrealistic. It's like, you can't have tea, you can't have coffee, the majority of your food is fruit intake. Like you have to consume a lot of fruits, it's nothing premade, you're allowed to have like one premade frozen meal per month. And the thing is people who are disabled, it's not easy to get on disability. So you are really disabled, like they are not able to cook, you know, and everything is kind of raw form unprocessed, you need to put it together, you need to make it and that's just not feasible for people. And so they usually end up running out of food stamps. And I've had patients where they've literally had to go days without eating because they were out of food stamps. So it's definitely really difficult. And yes, there are community resources, but there's just not enough to cover the amount of people that need more food.

Nicole Klem  13:48 
Wow. And so food security really, though is beyond the individual. This is a systemic issue that we see nationwide, and it impacts more people than I think the average person realizes. So I think, you know, nutrition education can play a role in this systemic food system/food security issue. How do you think we can make nutrition education more accessible to people who are challenged by food security issues like the one you described?

Katie Brown  14:20 
So there are some grants that will pay for like clinics for dietitians to work in, and then they'll see patients who maybe don't have insurance or their insurance doesn't cover it. And that's something that definitely we're trying to open more of them trying to get more of that access out to people. Definitely just more government coverage would be great, more coverage, you know, through Medicare, Medicaid, but even all the people that are uninsured, how do they get nutrition coverage, and they do have some free community programs that people can go to? There's some online stuff like the the USDA, but it's not really personalized and individualized, and I found that individualized care is really what makes big changes But that takes a lot of time and resources. So I'm not really sure how we can fix it without just, you know, giving everyone universal health care, which would be great for a lot of people, but it is something we definitely need to work on. And at least you know, even if someone's low income, they may with a dietitian, like we can help them with affordable ways to get food or meal prep or different things, you know, for, like, if they do struggle with being able to purchase food and make food, we can help them with those things, and guide them. So you know, even if we can't fix their underlying condition, or help their underlying condition, we can still help them in other ways.

Nicole Klem  15:34 
And I feel like some of those canned plans from the internet or from video may not be as culturally inclusive, as we hope. And I think what we're seeing in populations who are challenged by chronic conditions like heart disease and diabetes, the resources are out there, not necessarily the foods that they eat, or the way that they cook or familiar recipes and flavors and textures. So is there, you know, I think it's important that we as dietitians are trained to understand a wide variety of cultural eating and eating preferences and foods. So we can use the tools out there to customize that to an individual. Is there anything that the Academy of Nutrition and Dietetics, or the profession of dietetics is doing to fill some of these gaps or meet some of these needs?

Katie Brown  16:25 
So a lot of people that are part of the Academy of Nutrition, and Dietetics, which is basically the professional organization for dietitians, they actually end up being the majority of the board that makes up the Dietary Guidelines for Americans. So this is where they decide MyPlate, Food Pyramid, all of those things. And because we are mostly white women, the board ends up being mostly white women, and it kind of misses those other cultures. So definitely a big issue is education. And, you know, it's really interesting, because I just watched this webinar, and it was about how when dietetics first became a profession, black people were not allowed to go to college, and you're required to have a college degree. So there were all these people that automatically could not be dieticians. And a lot of those issues have continued. I mean, there's two historically black colleges, they don't have dietetics programs anymore. So really trying to figure out how we can get more diverse people into the field. And yet, like, you know, college tuition is rising, and cost of living is rising. So it's really hard for people to go to college. I think, you know, the newer education models are really helping, which I know you have the future education model. But actually, this is the most diverse year of students we've ever had. And if they all graduate and become dieticians, we will have the most diverse dietitians ever. So I think we're on the right path.

Nicole Klem  17:45 
Yeah. So you mentioned a little bit before we talked about weight bias and how society really views body size. So even in the the medical community, they pathologize weight. Can you talk a little bit more about what weight bias is and how it manifests in our culture,

Katie Brown  18:01 
I would say the biggest thing is that we see overweight people as being lazy or having low willpower. So doctors are actually less - they kind of assume that, oh, they wouldn't take their medication consistently or they won't be as compliant. And that's a really big issue. Because if going into an appointment, the doctor is already like, Well, hey, this thing could help this patient, but it's too difficult, they would never do it anyway, so I'm not going to recommend it, then they don't get the care they need. Other things are that doing certain tests on people who are obese or fat actually needs different tools. So like blood pressure, if you are taking it incorrectly on someone who is obese, it will come out incorrectly. And one of the things they actually think that drives increased mortality in obese people is actually medical errors, because doctors are not properly trained to treat people who are obese, because they are different. And so until we have a system where we can kind of properly care for those patients, we're always going to have these issues. You know, they also - if a doctor has two patients, one's thin, one's obese, they're more likely to spend more time with the thin one because they think, you know, they care more about their health, they're gonna put more effort in, and that's not always the case. So it really leads to systemic problems. The other big thing is a lot of mental health issues because even outside of medical practice, the stigma in general, the way society treats people who are obese, which at this point, I think a third of adults are obese and like 70% are overweight. So I feel like it's actually the norm. And yet people who are overweight feel like they're the outsiders when really they're the majority and so they have really poor self esteem and mental health issues and all those things. So then they're less likely to possibly get help or even just having you know, depression or feeling bad about yourself impacts your health. So it just all snowballs into additional issues.

Nicole Klem  19:50 
So there's an approach out there called Health at Every Size. It's been around for a while now but it has seen a lot of popular resurgence now in eating disorder community, nutrition community, registered dietitian community. So how would you describe principles of Health at Every Size for someone who wants to better understand it, who maybe hasn't heard of this or only heard a little bit about it.

Katie Brown  20:15 
So Health at Every Size is focusing on basically achieving your best health without focusing on weight loss. So there are so many different things we can do to help improve health without having weight loss. And more and more research is showing that a lot of times when people have improved health with weight loss, it's because they had improved healthy behaviors. So someone started exercising more, they lost weight, and their blood pressure improved. So they're like, oh, it's because you lost weight, when actually, it's because you exercised more. And so really kind of trying to focus on things you can do to be healthier without focusing on weight at all, like taking weight out of the equation. I do have to say that, you know, this movement has really - we have people that are very passionate about how we should never talk about weight, and we should never discuss weight. And I think that there's kind of a happy medium, like, we still want to be patient-centered. And if the patient really wants to lose weight, you know, even if it is for visual reasons, or they'll feel better about themselves. Yes, you know, we talk about the risks, the benefits, how difficult it is, stuff like that, but not really saying no, I absolutely won't help you lose weight. It's like, okay, yes, you know, we can work on your health conditions, and possibly help you lose weight at the same time. But definitely not overselling the likelihood of it. But overall, it's a really cool movement, because it kind of takes that part away where a lot of conditions, people are just like, well just lose weight. And if you take that away, you're like, okay, what else can we do for them? And I think it provides better care.

Nicole Klem  21:49 
Are there challenges to using a Health and Every Size approach?

Katie Brown  21:51 
Definitely. I mean, there's some people who think that it's not evidence-based, it's not ethical because obesity is this huge issue on how could you not treat obesity, but and you know, sometimes with patients that are very resistant, I definitely get patients who are just like, I absolutely want to lose a bunch of weight, and I want to lose it really fast. And I'll tell them, I'm not the right person for you. Because that's not what I focus on, or what I feel good about, a lot of people who lose weight regain it, and regaining the weight is more dangerous than just maintaining. So if someone's 200 pounds, and they maintain 200 pounds, if we can get them to like exercise or eat healthier, even if they maintain 200 pounds, their health will improve. If they lose, let's say 20 pounds, and then regain 20 pounds, their health is going to be worse. And in the long run, they didn't learn any healthy behaviors or they didn't incorporate any long lasting healthy behaviors. So I really think it's not good for the long term health of people to focus specifically on weight loss. I mean, I do think if you do it, right, it can have a place.

Nicole Klem  22:56 
Is it challenging when you have patients that might have built environment issues to exercise or nutrition knowledge and skill to prepare healthy meals or to access some of these Health at Every Size tools that aren't just focused on calorie reduction, you know, knowing that situationally, there might be other issues going on with that patient?

Katie Brown  23:21 
I would say one of the most interesting things is that exercise is not covered by health insurance, which kind of fascinates me that we're now covering nutrition, and we care about nutrition, but why can't you see a personal trainer as like a thing that's covered by insurance. So I definitely get patients who - there are a few managed Medicare plans that will still cover nutrition so I can see them, but they don't have the money to join a gym or have a trainer or anything like that. And they would really benefit from exercise. And especially, you know, if they are complex, like if they have, you know, spinal fusions, they need someone who really knows what is safe for them to do. So I'd say that is difficult. Obviously, if they have trouble driving, they don't have a car, getting to the gym is hard. And you know, where they live might not be good. Or let's say, you say everyone can walk, well, what if they have knee problems and they can't walk, or foot problems? Or a newer one I've learned about is POTS, which is Postural Orthostatic Tachycardia Syndrome, I think, is what it stands for. But basically, it's that you get really low blood pressure when you stand up and some people get it and you know, they stand up, it kind of equalizes, they're good. There's some people they cannot stand up ever, because they will pass out for long periods of time. So the idea of going on a walk is absolutely out of the question. Like they have to do something that's sitting and what is available to them, you know, like if they had a stationary bike, they could do that, but they can't afford one or, you know, how would they even get it into their house? Different things like that. So I would say there's definitely a lot of barriers and then you know, obviously mental barriers. So people who have autism, ADHD tend to have a lot of food texture problems. And so they'll have different issues with certain foods. So it's really hard to find foods that work for them. And then especially if they're low income, it's like, okay, well, you know, they struggle with fruits and vegetables. And you know, most of the ways that fruits and vegetables are the most palatable to people with these conditions is more expensive, you know, like having smoothies, but then you need to have a blender, and you have to buy this stuff for smoothies. So it's definitely challenging.

Nicole Klem  25:35 
Yeah, it sounds like you do some troubleshooting with your patients. Looking at their full picture, particularly as you're using some of those Health at Every Size tools. Another tool in your toolbox is something called intuitive eating. And I'm curious to hear your explanation of what it is, but also what it isn't, because I think there's a lot of confusion about what intuitive eating and the role it plays in, you know, someone's approach to improving their health.

Katie Brown  26:05 
So the way I like to start with intuitive eating is that they've done studies on three year olds, and they'll give them a juice box or whatever. And then they'll map - watch what they eat throughout the day. And they will inherently just eat that many less calories. So you can like sneak calories into a three hour diet, and they will just intuitively, like eat less at dinner. And so we're all built with the ability to do that. And even you know, you look at our grandparents, they didn't have nutrition facts labels. The Nutrition Facts Label actually didn't exist till the 90s. And people were healthier before it, which I feel like is an interesting thing to think about. But really focusing on how you feel and how foods make you feel and how they impact you. So you know, in a perfect world, you eat something with sugar, you eat something fried, you like it, it tastes good, but you don't feel so good. So you decide that maybe you're going to not eat as much of that next time. And that's how we're supposed to be psychologically. But then we've created this society that messes with our psychology so much. And now also parents and advertising and everything, that we no longer can connect to that properly and realize that, hey, eating this really sugary food makes me feel bad. So I'm going to eat less of it. And then you get into binge eating cycles, and all those other things. And so really kind of trying to go back to your roots of like, how does this food make you feel? And that's something I really do, is not even changing our diet. But be like, when you eat foods, think about how you feel afterward. And it's really good for people with chronic diseases to - let's say they have depression, did your depression get worse? Did your joint pain get worse? Did you feel more agitated? Did you feel tired? I mean, most people still get some amount of agitated, tired, nervous, you know, they drink a ton of coffee. And so starting to pair that, because then if you naturally pair with every time I eat this food, my joints hurt more, it's not so much that you're forcing yourself not to eat it, you will naturally start eating it less because you realize it makes you not feel as good. So then you're making changes without it being forceful. And kind of, oh, you need to be disciplined. And instead it's natural, and the way we're biologically meant to be. Does that make sense?

Nicole Klem  28:24 
It does. What are some things that you think people think that intuitive eating is, but it actually isn't?

Katie Brown  28:32 
I think people think it will help them lose weight. And I think people think it mostly is about fullness, and satiety, like, Oh, this is how much food I should eat, or oh, I'm eating too much fruit. And that's true. And that has like its place in a lot of things. It has not been shown to lead to weight loss, though, you know, without doing other changes as well. But I still think it's really, really good. And it actually ends up kind of ballooning to other parts of your life. So if you ever do mindfulness, mindfulness and intuitive eating are basically really similar. You're just being mindful about your eating and your food. And so it can really help with other aspects of life, like hey, maybe this exercise isn't working for me or this job or, you know, different things going on.

Nicole Klem  29:15 
Yeah, I love that I'm starting to see some mindfulness training in elementary and middle school. And there is a little bit of, you know, there's mindfulness curriculum, and then there's some intuitive eating when they get to food and nutrition. And so, you know, thinking about kids controlling thoughts and emotions around food may impact some of their practices or perceptions of food nutrition later in life. And that, you're right, mindfulness is really something that can infuse into the stress of any other life activity beyond even just eating.

Katie Brown  29:52 
Can I add something to that?

Nicole Klem  29:53 
Sure.

Katie Brown  29:54 
So I feel like sometimes actually, things like nutrition labels, calorie counting - it ends up undermining mindfulness because we spend so much time focusing on calories and protein and all these other things that we forget to just check in with ourselves and how we feel, like, do you like this diet? Is it working with your body? And so that's kind of what I was saying about the nutrition facts label is did that have something to do with it? Like, did it just make us so disconnected from how we feel? Because now we see numbers, and we're like, oh, we think we know better than our bodies, but we don't. And we really just need to listen to our bodies again.

Nicole Klem  30:29 
I remember, early on in practice while I was in school, you know, what's the best diet like, just tell me what to do? Right, you know, 10 years ago, and I was like, Well, the best diet's the diet you don't think about, right? It's just the approach to thinking more about your health and your hunger and your body and what you're craving and what your family enjoys, and what's in season far more than a very prescriptive, you know, I'm thinking this is like the time South Beach Diet was getting really popular and, Atkins diet was still on everyone's agenda. And they just wanted this prescriptive diet, when it's like, that will cause you more anxiety and stress and worry, and probably ultimately cost you more money, and feel less accessible than some of these Intuitive Eating principles and tools. And it's tough, sometimes I think as dietitians we shouldn't have the jobs we do, because it is ultimately telling people to look at what you eat, think about how you're feeling, practice the foods that you enjoy, and see sort of how, ultimately, that results in your goals. So at times, I feel like it's silly that we tell people how to eat but we're doing a lot more walking alongside people when it comes to using these tools. Health at Every Size and intuitive eating and meeting so many more people, different populations, different conditions where they're at. So one of my last questions is, how really do these types of interventions and tools shift away from traditional approaches that have been used in nutrition counseling, and where have we come from? And maybe, where is nutrition counseling and education going?

Katie Brown  32:09 
So I think it's really, really patient centered, which people talk about patient centered care. And I think sometimes we don't really embrace it to its deepest level, because then it's easy to be like, Hey, do you want this medication? Yes, or no. And then it's like, oh, they didn't want it. So we're going to try something else. And yes, on some level, that's patient centered, but you really have to know the patient, you have to know what they struggle with. And then also what they want to change. So sometimes a patient - you'll think, as an expert, that you need to change a specific thing, or they really need to stop drinking soda. But maybe to them, that's not what they want to work on. They want to work on, adding more movement or having healthier snacks. And so then you need to kind of be able to focus on what they want to focus on and look at what they're excited about. So yeah, I really think that is a big thing moving forward. I think a big thing is just really being very integrative. Because it is mental, it's emotional, you need to know the science. And then you need to be able to be practical about things. Because you can know the science and be like, this is the best diet ever. But are patients gonna want to do that? Does that work for that patient? So it's a lot of finesse, and really allowing everyone to be their own person, but helping them achieve their own goals.

Nicole Klem  33:26 
Excellent, I think, more optimistic about the direction nutrition counseling is going than ever before. Catherine, is there anything else you'd like to share about your practice, about food access, health equity, some of these topics that we've touched on?

Katie Brown  33:40 
Yes, so I was thinking. So all of this kind of ties together in some ways. So there's interesting stuff about how weight bias actually messes with intuitive eating. Because we're so worried about losing weight, we stopped focusing on how we feel when we eat certain foods. So that adds to it. And what's interesting is the cultures that are the healthiest don't really like they don't have a prescriptive diet. You know, they eat their cultural diet, kind of like what you're saying, but they don't think about it. Like they don't stress about their food. They're not like, oh, is this birthday party too many calories, they literally just go to their birthday party, they play with their friends, they do their normal lives, and they're healthy, and they're a good weight. And you know, they're really able to maintain that health. And one of the things some people speculate is that part of the reasons we have so much obesity is because we focus so much on being thin, that it creates disordered eating, which then creates obesity. So if we can move away from that and just be more accepting and caring towards everyone, then we can all be healthier, and we could possibly fix the obesity problem without even talking about weight loss.

Nicole Klem  34:44 
About weight loss. This also sounds like it goes beyond the profession of dietetics.

Katie Brown  34:48 
It does. I mean it's very, very interdisciplinary.

Nicole Klem  34:51 
Yeah. So all of our health care team, you know, should be learning a little bit more about the ways that we can approach food and nutrition and lifestyle. Do you have a lot of interprofessional work experience. Do you do some team care for any of your patients? Or, you know, is there changes in our health care system around the conversations of improving patient outcomes through nutrition?

Katie Brown  35:14 
Yeah, so team care is much harder in the outpatient setting than I feel like it should be. When I worked in a nursing home, it was very integrative. And I loved it, we actually had integrative meetings about a patient with all the different medical staff. And you know, we would talk about how this patient was doing. All of my patients, almost all my patients have therapists, that's something that, you know, it's kind of required, if they are struggling with emotional things, or body image things, they really need to have a therapist, so we definitely have that, and I would say, we don't really, let's say communicate very much, but we definitely work off of each other and talking with the patient, and you know, sometimes certain things, it's like, okay, you know, you should discuss this with your therapist, different things like that. So I would definitely say that you definitely need doctors involved for like labs, medications, other stuff, I definitely think it could be more interdisciplinary. And I think when you work at a clinic, like an outpatient clinic, where everyone else is outpatient, works really well. I kind of like the idea of having more holistic, instead of it being a doctor's office, where it's like, we're gastroenterology, I want, just, we're an office, and we have like a therapist and a doctor and a dietitian and a physical therapist. And everyone just communicates and cares for patients, because that's really what you need to have good patient outcomes.

Nicole Klem  36:32 
That's a great vision for health care model of the future. And I love what we do at UB and at least preparing our dietician students to understand the role that each of those other health professions play. And then to those health professions, the role of the dietitian hoping that eventually they'll, you know, hinge off each other for patient care. But having us all under the same roof would be a benefit to the patient for sure. I've heard this term food sovereignty out there, but I don't know much about it. What can you tell us?

Katie Brown  37:01 
So it actually loops back into a lot of the food access things. And so food sovereignty is having control over your own food. It's where you acquire food, make food, grow food. So a good example is where I live, I'm not allowed to have chickens. And so that's kind of a barrier between me being able to produce my own food. And it used to be that people could produce their own foods wherever they wanted, they could forage, they could hunt. And now we have more and more laws saying, well, you can only hunt these times of year, you can't forage in this area, different stuff like that. And so if we allow people to have more control over how they acquire food, they then can have less food insecurity. And there's really interesting stuff happening with that, like in Maine, they made a law that you cannot have any zoning limitations. So if you want to plant your vegetable garden in your front yard in Maine, you can do that. Now, if you want to have goats for goat milk, you can do that. There's none of these barriers. A really common one too, is even with food processing, and sanitation, which is important. But at the same time, they'll create such high costs to properly process the foods that then small farmers or individuals aren't able to do the things that they need to do to make their own food. So the idea is just having food access being more diverse, so you're not just going to grocery store, but what are other ways we can get food, and nourish ourselves and have control of our food environment.

Nicole Klem  38:27 
I know there's some environmental challenges, but I see folks who are from, you know, refugees from other countries fishing in the Niagara River all the time. And I'm thinking, you know, they're used to their waterways being a food access point, you know, we have different challenges here environmentally, with using that as food access. And so we've had to put these limitations on fishing in our waterways, essentially, because we know there might be some health concerns from the fish coming out of there, but that these folks are so used to using that as a food source. And we have to tell them on you know, no, we don't recommend it, you can't do it, you know, there's laws against it or recommending against it. So it's interesting that food sovereignty also might play into the environmental conditions in our neighborhoods, and then our built environment here.

Katie Brown  39:20 
So I have an interesting story. I went to the Cayman Islands, have you ever been there? So they have just fruit trees growing everywhere, like you just buy a house and it comes with a mango tree or like a coconut tree because it's tropical. And then they had a hurricane like 15 years ago, and all the chicken coops broke. And so now they're just wild chickens on the island. So if you put a roosting box, they'll just lay eggs in your backyard, and then you just have free eggs. So everyone on the island is just like, Yeah, I just got free eggs from my backyard. So it's just a really cool, different way to think about food and how to acquire food.

Nicole Klem  39:53 
Yeah, I feel like there'd be another conversation about the role of hunting and even our deer population and the ethics around food procurement of hunting, and how mixed people feel about that sometimes. Yeah, for another day. All right, this has been another episode of Buffalo HealthCast. Thank you to our guest, Catherine Brown, for taking time to speak with us today. Nicole Klem is our faculty consultant, Sarah Robinson is our production assistant, Omar Brown is our sound editor, and our theme music was written and recorded by Sungmin Shin of the UB Music Department. My name is Nicole, your host and writer for this week's episode. Thank you for listening and tune in next time to learn more about health equity in Buffalo, in the US, and around the globe. Thank you.

Intro  0:00 
Welcome to Buffalo HealthCast, the official podcast of the University at Buffalo's School of Public Health and Health Professions. We are your cohosts, Schuyler Lawson and Tia Palermo. In this podcast, we'll cover topics related to health equity in Buffalo, around the US, and globally. This season we'll be talking about nutrition from a health equity perspective. You'll hear from community members, practitioners, researchers, students, and faculty on topics related to nutrition, including food security, food access, social protection to improve nutrition outcomes, food apartheid, culturally tailored nutrition interventions, and more in this season of Buffalo HealthCast.

Nicole Klem  0:48  
Hello everyone, and welcome to another episode of Buffalo HealthCast, the University at Buffalo's premier public health podcast. I'm your host today, Nicole Klem, a registered dietician and Director of the Clinical Nutrition graduate program in the School of Public Health and Health Professions. It's National Diabetes Month in November and the CDC estimates there are 34 million American adults living with diabetes, and an estimated 88 million more may be at risk of developing the disease. Hispanic or Latino people make up a diverse group that includes people of Cuban, Mexican, Puerto Rican, South and Central American, and other Spanish cultures and all races. Each has its own history and traditions. But all are more likely to have type 2 diabetes - 17% more likely than non-Hispanic white people, who have an 8% chance of developing diabetes. But that 17% is just an average for Hispanic or Latino groups. The chance of having type 2 diabetes is closely tied to background. For example, if your heritage is Puerto Rican, you're about twice as likely to have type 2 diabetes as someone whose background is South American. With us today is Maria Aguero de Manunta, a registered dietitian and owner of a local private practice, and Clinical Director of the Clinical Nutrition graduate program. Thank you so much for taking the time to speak with us today. So I'll begin by asking you to tell me about yourself and why you started in nutrition and became a dietitian.

Maria Aguero de Manunta  2:19 
Hi. So I am originally from Paraguay, South America, and I moved to the United States with my husband and four children in 2001. We love Buffalo and now it is our home. I chose to become a dietitian because of my love for food. I grew up in a German town in my country, and one of the traditions in the town was baking wonderful German cakes and cookies. And after we finished with everything, we shared all these delicious pastries with friends and neighbors. And I can say that my love for food started when I was very young. I was always interested in working in the health care field to help others. And I thought that becoming a dietitian was a perfect career for me. I always wanted to learn more about foods and healthy eating. So I think when I started my nutrition career, this one, I learned a lot and I feel that I can help my patients and even friends and family who asked me about what is maybe the best food to eat if I have elevated cholesterol.

Nicole Klem  3:47 
That's really exciting. So this year's Diabetes Awareness Month is "It takes a team." Does the dietician work together with other health care providers?

Maria Aguero de Manunta  3:56 
Yes. The dietician work with other health care providers in the team, and we call this the interdisciplinary team.

Nicole Klem  4:07 
So what is the role of the dietician on that interdisciplinary team? And then what barriers do Hispanic and Latino communities face getting to that team or accessing that team?

Maria Aguero de Manunta  4:19 
The role of the dietitian in the interdisciplinary team is to work closely with other providers to manage and improve patients in the community health. As a member of a team, dieticians can help patients to meet their needs, not only about nutrition, but about any concerns that the patients can have. Because we are very closely working with providers and this interdisciplinary team, if our patient needs to make an appointment with the dentist, we can contact the patient and the patient can get that appointment faster because we are there, and sometimes we talk with our patients, and sometimes the patient says, "Okay, I really would like to see a counselor." So we have a counselor. If we don't have, in the place where we are working, we can refer to some counseling in the area, so that we can guide our patients not only if they have any nutrition concern, but about all their concerns. You mentioned, what barriers do Hispanic and Latino communities face accessing that team. When I did my Master's in Nutrition Science, I had to work on my thesis, and the topic of my thesis was assessing barriers that prevent treatment compliance in Hispanic adults with type 2 diabetes. And what I found was that the most significant barriers were lack of transportation in language and communication. My patients always said that they prefer to receive information in Spanish when they go to see their doctors or any providers. But sometimes they say that the doctors give them educational materials in English, and they cannot understand most of the information. Or I have a lot of patients that they cannot come to their appointments because they don't have transportation, and Medicaid offers cab or taxi. But sometimes they said, "I had an appointment with my doctor or with you, but they didn't show up, the driver didn't show up or the driver called and said, No, I cannot come", so they miss their appointments. So I believe that lack of transportation is a very important issue for them. The other barriers were access to health care and other providers, related to lack of health insurance, so they cannot pay out of pocket there. There's the consultation with the doctors, or if they have some oral health or oral problems, they cannot go to the dentist because they say that it's very expensive, they cannot afford it. So the limited budget is another barrier that I found. Other things that I found was family support and environment influence. So when they mentioned about this, they said that sometimes they want to follow maybe a healthy diet because the patient has diabetes, but because they have to buy the foods, and it's going to be very expensive, just buying for the patients who have diabetes. So they say that they have to buy - they have to cook the same food for the whole family. And sometimes they said they don't find that support in the family. So they if they have to follow a diet maybe very low in sugar, especially refined sugars, and they said, Oh my cousin brought for me some donuts or cookies and I cannot say no. So those are the most important barriers that I found when I did my thesis and the result those were. And this also demonstrated the need for qualified providers - dieticians who speak Spanish fluently, and understand that diverse Hispanic culture.

Nicole Klem  9:03 
All right, thank you. It must be a challenge really to overcome some of those barriers because of the limited numbers of providers that speak Spanish, particularly in areas like Western New York versus other, you know, more Hispanic- or Latino-dense communities. The CDC estimates that one in two people of Hispanic and Latino background may actually develop diabetes in their life, but it's due to so many reasons. Sociocultural factors like lower income, like you mentioned, decreased access to education and to health care, again, points that you made that are barriers, which may be due to a combination of language barriers, lower high school graduation, employment and lower wage jobs, some genetic susceptibility to obesity and higher insulin resistance. Racial inequity is also embedded in that health care system. So despite growing numbers of Hispanic and Latino communities, can you help us understand or explain why these communities are still underserved by dieticians, and how do you see things changing?

Maria Aguero de Manunta  10:03 
As I mentioned before, many Hispanics have a hard time accessing dietitian services because they do not have health insurance, or the health insurance that they have do not cover dietitian services. And they cannot pay out of pocket because I believe that dietitians charge maybe $80 to $120 an hour for their services. And they say that that is very expensive, because if they - some patients explain to me that if they go to see a dietitian, and they have to pay $80 for the dietician service, and then they are not going to have the money to buy the food. So it depends if the patient really doesn't have a limited budget, I think they have a very hard time to see a dietitian. I think that what needs to happen is that health insurance providers need to cover medical nutrition therapies in the same way that they cover all their medical specialties.

Nicole Klem  11:18 
How do you think that nutrition education and counseling could be made more accessible to the communities?

Maria Aguero de Manunta  11:24 
This is a complex social issue that needs are tackled from different front. The main one is education so that the community can understand what needs to be done. The professional community to raise awareness of the importance of these therapies, because I think dieticians, when they are doing their counseling, it's not just to help patients if the patient has diabetes, but it's to prevent disease. So we are here to counsel or to provide nutrition education to prevent maybe the patients can have diabetes in the future, can have cardiac events, can have hypertension. And also government agencies need to work with insurance provider to make nutritional services available to the larger population. And according to Healthy People 2030, the goal is to reduce the economic burden of diabetes along with the disease, and to improve the quality of life for people at risk, or who already have diabetes. And one of the objectives of Healthy People is to reduce the amount of new cases per year of diagnosed diabetes in the population and to reduce the diabetes death rate.

Nicole Klem  12:59 
Yeah, I hope we make some progress on those goals, unlike some other goals, and we see some reward for that effort. Would you tell me a little bit about your experience working at Neighborhood Health Center and with our Spanish-speaking Western New York community?

Maria Aguero de Manunta  13:14 
Yeah, Neighborhood Health Center has different locations. And one of their location is called Mattina, where I worked for six years, a little bit more, and the majority of their patients are Hispanic. They are really always looking for providers who speak Spanish. And they have a lot of representative staff who speak Spanish and these staff really help patients with all their needs. I was working as a Clinical Dietitian there, and 80% of the patients that I saw were Hispanic-speaking, so 80% of the patients that I saw every day, and they were really very happy because every time when I am with them, they said, "Oh, I am so happy because you speak Spanish and I can understand every single word that you say." Because once you speak Spanish, you can understand everyone in the world. If the person lives in Uruguay, I am from Paraguay, from Puerto Rico. So there are going to be maybe little words that are different, but that doesn't mean that we cannot understand someone who speaks Spanish. I can speak 100%, or maybe 99% with a person from Spain. So that's why the communication is very fluent, so we don't have any problems, and we also understand their culture. I learned a lot about Puerto Rican culture, Dominican culture here because when I was living in my country, we have our culture related to foods - it's a little different than food from Puerto Rico or from Dominican Republic. But I learned a lot with my patients. And I love their foods. And when I mentioned to them the food that we eat, they said, Oh my God, I want to try that food too. So there are very similar foods, but there are very different. Like when I was living in my country, I think I never tried tacos until I came to the United States. So I learned about Mexican food here in United States. So Neighborhood Health Center, they have one program that is called a sliding scale fee program. They provide some discounts for patients who qualify so they can offer their services to see dieticians, dentists, doctors, any providers there with a very low cost.

Nicole Klem  16:07 
Wow, what a great service and what a nice, sort of patient care model, you know, for our Spanish-speaking community in Western New York. In your experience, what kind of disparities do you see between the Hispanic and non-Hispanic communities in Buffalo related to diet and nutrition?

Maria Aguero de Manunta  16:25 
Based on my experience, I noticed that the Hispanic population has a higher tendency to acquire type two diabetes compared to the non-Hispanic population. Other things, too, is because they're low budget, they cannot go to the gyms or do physical activities, especially during the winter time. And so they start having more problems about elevated cholesterol, hypertension, and of course, then they can have any other health conditions.

Nicole Klem  17:04 
You do see it a little more often just because of some of those, maybe, you know, sociocultural barriers they've got, or different, you know, living conditions. In general, and I want to say even in education, we sometimes hear that Hispanic diets are unhealthy - high sugar, high fat from fried foods. But is that true? And would you tell me a little bit about the foods and recipes in the Hispanic diet and where maybe the bias or the assumption about their foods has come from?

Maria Aguero de Manunta  17:37 
The Hispanic diet is not one, but many, depending on from what country a specific community comes from, diets vary greatly. But in general, these diets are like most - they have good things and not good things like everywhere, I can say. On one hand, it is true that there is a high intake of sugars and fat, but on the other hand, Hispanic communities tend to avoid processed food and give preference to fresh home cooked meals. So most of my patients mentioned that they cook at home, but sometimes they, of course, they go to Burger King, McDonald's restaurants but they cannot even afford to go many days. Like maybe, I don't know, five times per week, but maybe sometimes they go one or two, but they really cook at home. When we go and review their eating habits, I know that some cultures - they eat more rice and beans than other cultures, or maybe less vegetables but one of my patients explained to me that in Puerto Rico they don't eat too much vegetables because they don't have a lot of vegetables over there or maybe in the area where this patient was living especially. And he said, So that's why they eat lettuce and tomato, but like in my country, we don't have, maybe broccoli, so we are not used to eating a lot of broccoli. If someone wants to eat broccoli, maybe, I don't know, they have to pay more than just buying lettuce and tomatoes. The same in Puerto Rico, but that doesn't mean that we don't eat vegetables. And there are some foods that are high in fat, such as the pork - it's called "pernil" in Spanish. It's so good, I love it. And these foods, it's very high in fat, but you can make a very lean pork too -a very lean pernil, and they have another meal or food that's rice and beans, or rice with ganulas, so the gandulas are very similar to beans. And they make some dessert, that one of their cakes is called torta de tres leches - it's very good, and I can say doughnuts, those are high in sugar but they don't eat like every day, so it's more like on special occasions. The other dessert is called flan. I love it. So, yeah, they have some foods that are high in sugar or fat. And some bananas, fried bananas, that I love it. But yes, but once they started learning about - they see the dietician, they they learned that they can still have those foods, but in moderation. It's not that they are not going to have them for the rest of their life, if they have diabetes, sometime they can have it. But they create a healthy routine, some patients who are - who really need to make some changes in their diet.

Nicole Klem  21:18 
Where do you think some of the assumptions that it is unhealthy have come from? Do you think it's just because we see brown rice, chicken and broccoli as healthy? And we don't see rice and beans and lean pork as healthy? Or? Yeah, where do you think some of the, I don't know, assumptions that that diet is unhealthy have come from? Because you're right, we have chicken wings, and doughnuts and pizza, plenty of unhealthy things in our diet, but we maybe aren't as critical or judgmental on, you know, the diet we eat here versus a different cultural diet.

Maria Aguero de Manunta  21:53 
Yeah, so I think it's because maybe the portion sizes than what they are eating because they love - Puerto Rican people love rice and beans. And when I mentioned that to my patients that they have - or what is the portion size that you are eating about your rice and beans, and they said, show me about the fists of your hands. So they start laughing when I show them that the recommendation is to have one fist of the hand, and they start laughing they say Oh my God, I maybe have two or three or four or full of my plate. But once they learn what is the recommendation about starchy vegetables and grains, they really start cutting down the portion sizes. And, of course, they have, as I mentioned, like fried bananas or other foods that are high in fat. But I believe that maybe that is more related to the portion sizes.

Nicole Klem  22:57 
You know, and I guess you kind of lead into my next question, because if there is some truth to that - maybe the portion sizes are a little bigger foods, are there specific recommendations that you give them to modify their diets, while still telling them they can include some of these favorite foods? So maybe reducing the portion size slightly? Are there other tips that you give them to enjoy the foods that they enjoy, but still, you know, move towards maybe a more, you know, healthier choice overall?

Maria Aguero de Manunta  23:26 
Yes. And as dietitians, we have to be very careful when we provide nutrition education to our patients, because we have to take into considerations their culture, their beliefs. So we cannot just walk with our patients, even not just, I would say not just Hispanic, any person in the world, we have to learn about their cultures, what their preferences, we cannot just go to a patient or a patient who is Asian patient who they love rice. And we cannot say, You cannot eat rice anymore. So we have to go and understand what they want and what they believe. And then of course, we can start with our nutrition education and recommendation. And because there are other factors, like I don't know, maybe the biggest factor is the one of the budget. So we cannot recommend a patient to eat salmon if the patient have elevated triglycerides, but there are options, so we can tell the patient you can eat tuna fish, which is cheaper or they can get from their food pantry. So we have to be very careful about that in any recommendations that we are giving to our patients and understand first what our patients want. And based on that, we can start and do the recommendations. I always recommend my patients to have the rice and beans or rice with gandulas in moderation. I recommend them to have half of their plate with a starchy vegetables. Or if they cannot go so fast to that portion size, I told them gradually, maybe you can start reducing that and adding more starchy vegetables. And we go over to how to prepare meals, maybe better bake or grill chicken or any meat, lean meats and you're not going to believe but at the next visit, they said, Oh, I buy the air fryer, so they want to make those changes, because they know that this is important for their health.

Nicole Klem  25:55 
Yeah, that sounds like small changes could really add up but also preserve some of their favorite flavors or foods or dishes. So where do you go to find reliable resources or tools for your patients or for Spanish speakers?

Maria Aguero de Manunta  26:13 
I go a lot to MyPlate.org because they provide a lot of recipes in Spanish and English, even they have now in so many different languages. So if I have a patient from Arabic or Africa, they have a lot of options now in those languages. And when I was working at Neighborhood Health Center, we develop our educational materials, I think now they have five different languages. So Arabic, I cannot remember very well, but they have a few educational materials in other languages. So MyPlate.org is a very good resource, very reliable. Centers for Disease Control and Prevention, the CDC, they have materials in Spanish and the American Diabetes Association.

Nicole Klem  27:16 
Yeah, really fantastic resources for us to build our toolboxes. Well, thank you this has been really wonderful. Is there anything else you'd like to share?

Maria Aguero de Manunta  27:26 
I believe that it is important of providing more bilingual services and qualified dieticians, who speak Spanish fluently and understand the diverse Hispanic culture, as well as funding for programs to reduce the financial burden of these segments of the country's population. Because low income and a relative lack of financial resources can severely impact a patient's ability to treat diabetes and other chronic conditions effectively.

Nicole Klem  28:05 
This has been another episode of Buffalo HealthCast. Thank you to our guest, Maria Aguero de Manunta, for taking time to speak with us today. I'm your faculty consultant, Nicole Klem, Sarah Robinson is our Production Assistant. Omar Brown is our Sound Editor. And our theme music was written and recorded by Sungmin Shin of the UB Music Department. Again, my name is Nicole Klem, your host and writer for this week's episode. And thank you for listening. Tune in next time to learn more about health equity in Buffalo, the US, and around the globe.

Intro  0:00 
Welcome to Buffalo HealthCast, the official podcast of the University at Buffalo's School of Public Health and Health Professions. We are your cohosts, Schuyler Lawson and Tia Palermo. In this podcast we'll cover topics related to health equity in Buffalo, around the US, and globally. This season we'll be talking about nutrition from a health equity perspective. You'll hear from community members, practitioners, researchers, students, and faculty on topics related to nutrition, including food security, food access, social protection to improve nutrition outcomes, food apartheid, culturally tailored nutrition interventions, and more in this season of Buffalo HealthCast.

Sarahmona Przybyla  0:47 
Hi there, my name is Sarahmona Przybyla. I'm in the Department of Community Health and Health Behavior, and today we're going to be interviewing Jacob Bleasdale, who is a fourth year PhD student in the Department of Community Health and Health Behavior at the UB School of Public Health and Health Professions. So Jake, I'm just going to jump right in with some questions if that's okay. I think it's important for us to hear a little bit about how you became interested in HIV prevention and treatment research.

Jacob Bleasdale  1:13 
Yeah, absolutely. So historically, and within present day, we know that the HIV epidemic has affected marginalized communities, particularly the queer community. And as a member of the queer community, it was important to me when deciding on a career path that my work that I was doing was based in equity and justice and work towards providing better health for a particular group. So working to end the HIV epidemic through research is what I decided to do. And that's how I came about with HIV prevention research. It also kind of just bridges my two interests. So my undergrads are in Biomedical Sciences in Pharmacology and Toxicology. My PhD is obviously in Community Health and Health Behavior. And HIV research combines both that Biomedical and Behavioral Sciences and allows me to give a nice lens to the work that I'm doing, but also understand the full complexities of the epidemic itself.

Sarahmona Przybyla  2:03 
Great. Tell me a little bit more, though, about the difference between HIV prevention versus HIV treatment, because I understand those to be related, but not the same thing. So talk a little bit more about that.

Jacob Bleasdale  2:13 
Yeah, absolutely. So when we think about HIV prevention, we're primarily thinking about people who are not living with HIV, or HIV uninfected people and preventing them from getting HIV. So most of my work and the work that we do in our work and our research really focuses on increasing HIV pre-exposure prophylaxis, or HIV PrEP uptake within communities that are most at risk for HIV acquisition. So that includes communities of color, men who have sex with man, gay and bisexual men. So really focusing on increasing PrEP uptake for those communities. Then on the other hand, you have HIV treatment, which includes really amplifying engagement across the HIV care continuum. So that includes making sure that people who are living with HIV receive a timely diagnosis, are engaged in care and then take their medication enough so that they're virally suppressed, or the HIV in their body is so low, it cannot be detected on a viral load test. So that's HIV treatment research - it really focuses on bolstering and amplifying engagement across the care continuum and making sure that people who are living with HIV achieve and maintain viral suppression.

Sarahmona Przybyla  3:20 
That's great. Okay, so now I want to ask you a little bit more about nutrition, right? So this is a different path. But how did you become interested in nutrition and food insecurity research?

Jacob Bleasdale  3:32 
Yeah, absolutely. So my first exposure to nutrition and dietary and eating behavior work was in my undergrad. So I worked as a research assistant all throughout my undergrad in the Child Health and Behavior Lab in the Jacobs School of Medicine under the direction of Dr. Stephanie Anzman-Frasca,
 and in this lab, I really learned a lot about developmental psychology and early childhood health behavior in relation to obesity prevention. So we focused a lot on nudging techniques and techniques that would make the healthiest choice, the easiest choice for children to prevent obesity. And when I decided to pursue a PhD, and really focus my work on HIV prevention and treatment, I really wasn't ready to give up the nutrition aspect of that yet. So I decided to look at how dietary intake and food insecurity would start to influence HIV treatment outcomes for those living with HIV. And that's kind of how I have been marrying the two within my work a little bit.

Sarahmona Przybyla  4:23 
I think food insecurity is a term that a lot of people use, but not everybody may understand what it means. So what does food insecurity actually mean?

Jacob Bleasdale  4:32 
Yeah, absolutely. So broadly speaking, when we think about food insecurity, we are talking about it with people we think about lacking access to food or not having food within the household that meets sufficient needs. So whether that's access in terms of physically having the food or access about getting the food, it's really just not having the needs to get an ample and a sufficient amount of food for you or your household.

Sarahmona Przybyla  4:55 
Got it. Okay, great. I want to bounce back to HIV. So tell us a little bit more about what HIV looks like in the United States.

Jacob Bleasdale  5:03 
Yeah, absolutely. So we've definitely made strides since the beginning of the epidemic in the late 80s and early 90s. But even still in 2020, we had about 31,000 people in the United States who were diagnosed with HIV. And of those diagnosed with HIV, we're still seeing significant disparities. So among those, 70% were among gay, bisexual, and other men who have sex with men, 22% were among people who identified as heterosexual, and 7% were among those people who inject or use drugs. Currently in the United States, there are approximately 1.2 million people living with HIV. And while HIV diagnosis has decreased about 8% overall, there are still stark disparities with new HIV incidence. So we see a lot of new diagnosis primarily among Black and Hispanic men who have sex with men, and among other disparate groups of people within the United States.

Sarahmona Przybyla  5:53 
So that's great to hear what HIV looks like on a national level. How about closer to home? Can you talk a little bit about what HIV incidence or prevalence looks like, either here in Buffalo, or more broadly, maybe in Erie County?

Jacob Bleasdale  6:07 
Yeah, absolutely. So it's nice to contextualize what HIV or the work we're doing looks like in Buffalo and Erie County. So in 2020, Erie County had about 85 new HIV diagnoses, which is actually the highest number in the state outside of New York City, and those number of diagnoses in Erie County has decreased in 2018 and 2019, but actually in 2020, was the first time it's actually increased. So among these new infections, we saw that 63% were among non-Hispanic Black persons, 69% were actually among people ages 13 to 34, and 58% were among men who have sex with men. So we see that the number of new diagnoses and among the new diagnoses in Buffalo kind of represents and contextualizes on to the steps that we see at the national level as well.

Sarahmona Przybyla  6:53 
So that's actually really interesting to hear some of those 2020 numbers, because that's when we entered the early years, early months of the pandemic. So talk a little bit about how may that have happened, right? I guess we might assume that HIV cases would have gone down, and especially when you know, the first few months, or even first half of 2020, what might explain that pattern you see?

Jacob Bleasdale  7:15 
Yeah, so the intersections between HIV incidence and COVID-19 are complex and interrelated. And we're still working very hard to figure out what those complexities are. But a lot of people have hypothesized that the COVID-19 pandemic has led to decreases in HIV testing, which would increase not only the proportion of people who are diagnosed with HIV, but also decrease what as people's statuses. So one of the major things of HIV prevention is knowing your HIV status. We know that one in seven people who are diagnosed with HIV were unaware of their status. So a lot of researchers hypothesize that that is a major contributor to what we see, an increase in HIV incidence is that people weren't getting tested during the pandemic, but still engaging in risky sexual behaviors, despite social distancing guidelines and the risk of contracting COVID-19. But because of that, and because health centers are shifting gears towards treating and maintaining COVID-19 infrastructure, there was less testing that was potentially available, or people just were not willing to go get tested. So a major hypothesis is that less testing led to more unknown cases of HIV, which led to greater incidence within 2020.

Sarahmona Przybyla  8:31 
That makes sense, okay. So let's flip back to food insecurity. Can you give us a sense of what food insecurity looks like across the United States?

Jacob Bleasdale  8:41 
Yeah absolutely. So in 2021, about 90% of households were food secure. So they had adequate means to get the food that they need to support themselves. So that leaves about 10% or 11% of households that were food insecure, at least sometime during the year. And this includes 3.8% or 5.1 million households that had very low food insecurity. So the lowest bracket that we can think of when we're measuring food insecurity is very low food insecurity, which is very severe - severe lacking access to food or not having the ability to maintain the nutrition that they needed to survive. And we also see that this is highly correlated to socioeconomic status. So 32 or 33% of households that were food insecure, were among those with incomes below the federal poverty line. And rates of food insecurity were substantially higher for single parent households, and for Black and Hispanic households as well.

Sarahmona Przybyla  9:38 
You mentioned socioeconomic factors. Can you talk a little bit about either maybe geopolitical or even other economic drivers of food insecurity? So what comes to mind is things like inflation, right, and how we see our grocery store bills going up. How do those changes, you know, kind of differentially impact those who are food insecure?

Jacob Bleasdale  9:58 
Yeah, absolutely. So when we think - I think when we think about affording food and affording groceries, the first thing we think about is income, and inflation, it's definitely impacted what we can afford at the grocery store. I know, even personally, when you go to the grocery store, eggs are significantly more expensive than what they used to be. But another factor that plays a significant role in food insecurity, or food security status is actually access and having transportation to get to these areas or get to areas that have adequate food for your family. We know that the historical ideas of redlining or intentionally segregating areas, has influenced where grocery stores go not only here in Buffalo, but also across the United States. So one of the biggest factors that influence food insecurity is actually being able to have access to these grocery stores and lacking transportation, or not even perhaps lacking transportation, but someone may not want to have to take five buses and spend $4 just to get to the grocery store and then have to take that back. So access and transportation concerns plays a large role in food security and food insecurity status in the United States.

Sarahmona Przybyla  10:01 
Got it, makes a lot of sense. Are there any other things that you want to share with us about food insecurity, just generally speaking?

Jacob Bleasdale  11:15 
I think it's also important to contextualize it within Buffalo as well. So in 2020, nearly 56,000 households or 12% of all households in the Buffalo Niagara community lacked equitable access to supermarkets because they lived outside the average walking distance from shopping. So that kind of goes back to this idea of lacking adequate transportation or access to grocery stores. And a lot of this is predominantly within black and brown neighborhoods that have been redlined by supermarkets and grocery stores, so that these areas are politically and economically not able to fund or have their own grocery stores in these areas which significantly impacts access for people who live in Buffalo communities that don't have a Tops or a Wegmans right next to them. So it's an issue on the national level, but it's also a significant issue that hits very close to home within our Buffalo community.

Sarahmona Przybyla  11:30 
Sure, yeah. And I think maybe something that many of us might take for granted.

Jacob Bleasdale  12:09 
Absolutely.

Sarahmona Przybyla  12:10 
For sure. Okay. So you've shared with us a lot about HIV prevention, HIV treatment, and then this kind of parallel research world for you with respect to nutrition and food insecurity. How about this intersection, though, right? So talk to us a little bit about how HIV, nutrition, and food insecurity intersect.

Jacob Bleasdale  12:10 
Yeah, I think when you first think about HIV and food, you're like, there's no relationship there, or it's hard to contextualize the relationship between the two. But there's actually a significant relationship between not only food and nutrition and HIV, in terms of the biomedical and pharmacokinetic level, but also at the health care engagement level, and at the more social ecological level as well. So first, we know that research has illustrated significantly higher prevalence of food insecurity among people living with HIV compared to the general population. So like I said earlier, it's estimated that about 10 to 11% of the population in the US experienced food insecurity in 2020. But we have cross sectional longitudinal data among people living with HIV that estimates food insecurity, rates and prevalence to be about 25% to 70%. So we see a significant disparity in food insecurity affecting people living with HIV compared to the general population. Then we also just see significant risk factors that increase the risk for food insecurity among people living with HIV. So we see behavioral mental health concerns, illicit substance use, and the socioeconomic factors like we discussed earlier, such as low income, unemployment, unstable housing, transportation that all kind of compound and intersect together to significantly increase the risk of experiencing food insecurity while living with HIV.

Sarahmona Przybyla  12:34 
Got it, okay. I now want to hear a little bit more about this influence on HIV treatment and HIV prevention. So talk to us a little bit maybe about your own research of how food insecurity influences HIV treatment.

Jacob Bleasdale  14:13 
Yeah, absolutely. So we know that among people living with HIV, food insecurity is associated with lower odds of completing healthcare outcomes or just lower odds of greater health outcomes. So we know that that means lower CD4 cell counts or HIV in the body, incomplete viral suppression. So people are having detectable HIV viral loads in their body which has the potential to increase transmission. They have worse immunologic responses so they're more likely to get sick easier, and they have increased opportunistic infections that are associated with HIV and AIDS as well and poor medication adherence. So those, for people living with HIV and HIV treatment, all kind of interplay to kind of influence health outcomes for people living with HIV that kind of decrease one's ability to maintain and achieve viral suppression, which is that last stage of the HIV care continuum, which we are trying to do.

Sarahmona Przybyla  15:11 
So I know that you do qualitative studies, and you interview people living with HIV. Can you give us maybe some examples of how this actually plays out? So you're making these connections between food insecurity, and you're talking about connections to treatment engagement, but how does that actually work in someone's day to day life?

Jacob Bleasdale  15:31 
Yeah, absolutely. So I recently just had a paper published in Tropical Medicine and Infectious Disease that looked at the influence of COVID-19 on HIV care engagement among people living with HIV, and my sample was 25 people living with HIV across New York State, the majority were food insecure. A lot of them talked about how the pandemic and food insecurity influenced their social determinants of health, so particularly income, housing, and transportation, and how that led to decreased engagement in care. People talked about just how food insecurity in general was significantly impacted by COVID-19, and how that led to increased periods of time where they didn't have food, and that increased their depression or their anxiety, and they physically felt weak, and they weren't able to go to their doctor's appointments, or they weren't able to take their medication. And a lot of our participants just talked about how, when you don't have food, the last thing on your mind is taking care of your other health needs, my main priority is going to find or do something so that I can eat dinner for the day, but the last thing on my mind is going to talk to my doctor or to take my medications. And a lot of these medications, people don't like to take on an empty stomach. So if they don't have food, they're not going to take it.

Sarahmona Przybyla  16:45 
That's a really good point about how the medicine actually works in their body, and that you need to take it with food, but food isn't available to you. You can see how that affects the way people make choices about their taking their medicine.

Jacob Bleasdale  16:46 
Absolutely.

Sarahmona Przybyla  17:00 
Are there other ways that the COVID-19 pandemic has influenced food insecurity? And how people living with HIV kind of manage their illness?

Jacob Bleasdale  17:09 
Yeah, absolutely. So a unique finding in our study was this idea of social support or support from other people within a person's social network. And despite other studies that have found significant social isolation and decreased social support among people living with HIV during the COVID pandemic, we found, or our participants described how during the pandemic, they actually had increased social support from families and friends and loved ones and clinicians that kind of helped them with receiving these material needs. So in times where they had insecurities such as housing, food, these people kind of came up and served to help them get food or to provide them housing or to give them the resources so that they were able to get a meal for the day. So that was a unique finding that we found that kind of really drives home, this idea of how social support acts as intrinsic motivation for engagement across the care continuum, despite the pandemic going on.

Sarahmona Przybyla  18:03 
You mentioned the social support, and you've talked about family and friends. But then you also talked a little bit about health care providers or other maybe social service providers. Talk a little bit more about how non-family members, non-friends can really help with tackling the food insecurity challenges that people living with HIV might experience.

Jacob Bleasdale  18:20 
Yeah, absolutely. So in our study, we found that a lot of participants got emotional and informational support from their healthcare providers or case managers and counselors. And that emotional support of encouragement to continue with their care, despite these challenges, really became internalized among people and participants really felt that their providers cared for their well being outside of their HIV. So that kind of became internalized for people to stay motivated to engage in their care and take their medication. But on the opposite side, it also made them more comfortable to talk about other needs that they had. So a lot of our participants were in unstable housing, did not have incomes, or lost incomes due to the pandemic, or even didn't have food to eat. So a lot of case managers, counselors and even healthcare providers and clinicians provided resources that allowed our participants to go within the community and find maybe a hot meal for the day or help them find, or give them the information to a shelter that would allow them to stay there for the night. So the social support expands beyond one's loved ones to include the health care sector as well. And that's a really important thing to drive home when we're thinking about HIV care engagement as well.

Sarahmona Przybyla  18:21 
So you're a public health practitioner, you're a public health researcher, how can other public health researchers and practitioners work to really reduce food insecurity among people living with HIV?

Jacob Bleasdale  18:45 
Yeah, absolutely. So it's really, when I think about it, I think about approaching it from the social ecological model, thinking about the interpersonal, the community, and the policy levels of that, so really leveraging that social support to ensure timely and successful engagement. So we know that HIV stigma still runs very rampant within our society. And that is unfortunately the case within families as well. So ensuring that we can reduce HIV stigma within the community to ensure that people have social support when they are, or if they're diagnosed with HIV to ensure that healthcare providers have the information to help them stay engaged. Then also just leveraging health policies and public health infrastructure. So one thing to think about is increasing Supplemental Nutrition Assistance Program or SNAP benefits. So we have seen in the COVID-19 pandemic that some SNAP benefits just may not be enough when combating with HIV and on other crises such as COVID-19. So increasing those benefits so that people have more money and aren't stretching the dollar at the end of the month. But then also amplifying strategies that increase HIV care engagement, such as programs like Data to Care, which is an HIV surveillance program. So they use healthcare provider and health department models to identify people who are engaged in care but aren't virally suppressed. So what is that disconnect between being engaged in care, but you're still having detectable HIV in your body. And it's really taking that Data to Care program and stretching it beyond the healthcare or the siloed idea of medicine, and looking at what other material needs may be impeding someone's successful engagement. Perhaps it's housing, perhaps it's food, perhaps it's income that's inhibiting someone from taking their medication. So they're showing up for their appointments, but if you're not taking your medication, you're not going to be virally suppressed. But if that's because of income, if that's because of food, integrating those programs so that these programs not only have epi data and surveillance data, but also are able to look at these more sociostructural factors that impact care, and have solutions or abilities to engage and intervene on them.

Sarahmona Przybyla  22:06 
You mentioned stigma earlier about people living with HIV. I'm wondering if you have some thoughts on what you hope the general public would know about people living with HIV who experienced food insecurity, or maybe some misperceptions or misunderstandings? How can we do a better job of helping to kind of demystify HIV, or work with respect to food insecurity among people living with HIV?

Jacob Bleasdale  22:31 
Yeah, absolutely. And I think what you said, like demystifying HIV as an important thing that we still need to strive for, not only within our work, but also as a society as a whole. And I think what's really important is that people living with HIV are the same as everyone else, they're just living with a disease, and now with the antiretroviral therapies and engagement and care, we're looking and treating HIV as a chronic disease that's manageable and manageable with proper medication and care, similar to what we do with diabetes. So shifting the mindset from HIV being this infectious disease, which it still is, but to a more chronic manageable disease, is really important for the community to think about. Because back, there was a lot of myths that came out within the early times of the HIV epidemic. And I still think some of those are prevalent within the communities, but not because of ignorance, but because people just don't know. So really working with our communities, us as public health practitioners, researchers, health departments really getting out there to inform the community about HIV, make sure everyone knows their status, despite their risk factors. Because the more we do it, the more we'll normalize it, and the more we'll start to treat HIV as a chronic disease such as diabetes, instead of this death sentence that it was 20, 30 years ago.

Sarahmona Przybyla  23:52 
How about next steps for you, Jake, where do you see your future research about this intersection with food and nutrition, food insecurity within the realm of HIV?

Jacob Bleasdale  24:03 
Yeah, that's a really good question. So my goal is to really focus on starting to take this data that we have, and translating it into intervention work. So we have all this longitudinal and cross sectional data that shows that food insecurity, and nutrition-related and dietary-related stuff is much lower among people living with HIV, but what can we do about it within our community, so really looking at more like a social ecological approach to addressing some of these disparities within the communities, making and sustaining interventions within the communities is really what I strive to do. And I think that's how we're going to combat some of these issues. So yeah, those are kind of my next steps.

Sarahmona Przybyla  24:46 
Are there any other final concluding thoughts you'd like to share with us, Jake?

Jacob Bleasdale  24:49 
No, I think we covered them all.

Sarahmona Przybyla  24:51 
Great. This has been another episode of Buffalo HealthCast. Thank you again to our guest, Jacob Bleasdale, for taking the time to speak with us today. Nicole Klem is our faculty consultant. Sarah Robinson is our production assistant. Omar Brown is our sound editor. And our theme music was written and recorded by Sungmin Shin of the UB music department. My name is Sarahmona Przybyla, your host and writer for this week's episode. Thank you for listening and tune in next time to learn more about health equity in Buffalo, the United States, and around the globe.

Intro  0:00 
Welcome to Buffalo HealthCast, the official podcast at the University of Buffalo's School of Public Health and Health Professions. We are your cohosts, Schuyler Lawson and Tia Palermo.  In this podcast, we cover topics related to health equity in Buffalo, around the US, and globally. This season we'll be talking about nutrition from a health equity perspective. You'll hear from community members, practitioners, researchers, students, and faculty on topics related to nutrition, including food security, food access, social protection to improve nutrition outcomes, food apartheid, culturally tailored nutrition interventions, and more in this season of Buffalo HealthCast.

Tia Palermo  0:39 
Hello and welcome to this episode of Buffalo HealthCast. I'm your cohost, Tia Palermo. Today I'm going to be talking to Jennifer Matafu, who is a Social Protection Specialist at the United Nations Children's Fund for UNICEF, Tanzania. Jennifer is going to be talking to us today about social protection, which is a set of policies and programs aimed at preventing or protecting all people against poverty, vulnerability, and social exclusion throughout their life course with a particular emphasis towards vulnerable groups. Can you tell our listeners a little bit about the work you do for UNICEF?

Jennifer Matafu  1:30 
Okay, my name is Jennifer Matafu. I'm a Social Protection Specialist working in social protection. Social protection is about working for the most vulnerable people who are at risk and the people also who are living in very severe conditions. So my work is much more social protection, in terms of helping people in different programming or helping the government through policy or helping the government through developing systems to support the most vulnerable people in our country.

Tia Palermo  2:09 
And the Tanzanian's Productive Social Safety Net, or the PSSN, is one type of social protection program. It covers 1 million households in Tanzania. Can you tell us a little bit about the PSSN?

Jennifer Matafu  2:24 
Yes, PSSN is Productive Social Safety Net - it's one of the social safety net programs. It covers about 1.3 million households in Tanzania.  In Tanzania is the union government, comprised of Tanzania mainland and Tanzania Zanzibar, so we usually call it Mainland and Zanzibar, and it is providing cash transfer to the most poor people household in the country. PSSN provides cash transfer in three forms. One is for income and consumption and to ensure also children go to school, and those who have under five children are taken to clinic. But at the same time the PSSN provides a livelihood component, which provides an additional skill enhancement for the poor families to be able to come together that as a saving group, to save and get some credit to be able to improve their livelihood. And lastly, the PSSN program provides also an opportunity to get extra cash by doing public works, especially during the dry season when most of the people who are in the rural areas, it's not raining and they do not - they don't have an opportunity to earn or get food. So they do some public works like building some roads, improving roads, building some school facilities, and they get paid. And that money helps them again to be able to consume some food and also for the basic necessity for their household.

Tia Palermo  4:12 
So this is a very large anti poverty program in Tanzania targeting the extreme poor and providing them with monthly assistance through cash payments and public works and savings groups as you mentioned. Given that the PSSN is run by government, what is UNICEF's role in supporting the PSSN?

Jennifer Matafu  4:34 
UNICEF's key role is helping the government/national level put the policy and legislation in place to be able to have some kind of safety net to support poor people who are extremely poor. 2) UNICEF has the role for children. UNICEF has the mandate to support all intervention supporting children, and in the PSSN program, most of the household, half of the people who are covered, usually called beneficiaries, half of them, about 2.3 million, are children from under 5 up to 18 years old. So UNICEF's role, because given its global mandate, is to ensure that these children are able to get proper nutritious food - by the cash that they're given, they provide nutritious food. 2) They go to school. 3) Some of those who cannot go to school are supported with some sort of skill and has been or encouraged to continue school in different level. So UNICEF's role really supports the children, but also looking at the poverty level at the community level, to be able to support them today so that they can have enhanced or improved life, and somehow get through the poverty cycle, which is always an issue for the people who are very poor.

Tia Palermo  4:34 
Thank you. Can you tell us if there have been any research studies evaluating the effectiveness of the PSSN and what these have found?

Jennifer Matafu  6:17 
Yes, there have been. PSSN program has gone through Phase One. And Phase One of the program, which was like 3-4 years ago, there was an impact evaluation and key findings or recommendation coming from the impact evaluations, the cash which was provided to the household enabled a lot of children to go to school, enabled for families to be able to buy uniforms, and school supplies for their children to go to school, and also enabled especially women or pregnant mothers to attend health clinic. The taxed provision of cash transfer, which they did not have, was some sort of an accelerator to support them to reach out for the basic social facilities, education, or health. But also, the impact evaluation study shows that there is some sort of progress in terms of families, improvement of family household. Some few families who are able to get through the saving groups, which I mentioned before, to get some credit, and sort of start a business, small business, not a big business, small business, like a farming or poultry, or a small shop. And they have been able to improve the income, the city income in their family. So that impact studies, it sort of shows that there's no negative impact in providing cash to poor families.

Tia Palermo  7:54 
Thank you. So even though this might not seem like a lot of money to some of our listeners here, this is about a maximum annual benefit cash transfer that we're talking about in Phase One - about $195, which comes out to about, you know, a maximum of $15 or $16 a month, but what you're telling us is that for extremely poor families, this is making a big difference in their lives. Is that right?

Jennifer Matafu  8:25 
Yes, right. Because most of the families who were part of the program, before the program, there was an assessment, and most of them they didn't have, they only had one meal a day. So now most families are either having two meals a day, or they're having three meals a day, depending on each family - it's a little bit subjective. $16 for a lot of people who would think it's not possible to make a difference. But for the people who are extremely poor, having a second meal is is an improvement, a huge improvement. Without that, most of them, they go back to having either one meal, or having no meal at all. Cash transfer - global evidence has shown that it can improve family's consumption, and it can improve family's livelihoods to make a family better, because now you're just finding them an opportunity to be able to do something which initially they did not have.

Tia Palermo  9:29 
Right, thank you. So you've talked a lot about hunger and meals and being able to afford more meals per day. Can you give us a little bit of a background about children's nutrition in Tanzania?

Jennifer Matafu  9:44 
Malnutrition and stunting is a big problem in Tanzania. And we know that nutrition is somehow related to poverty because people don't have money and then the consumption of food, they don't have a choice. They eat what they have. So by being provided with the cash, the bimonthly cash, then now they can have a choice to choose nutritious food, the second meal. So, from the problem itself, most of the poor families, now that they have the opportunity to have two or three meals, then there is a demand or the need to sort of help them make the best selection in terms of nutrition to choose the nutritious food for their babies. Also for their children, for the whole family. The statistic in Tanzania, stunting or malnutrition is 34%. And that's huge. And the more poor the people are the more likely to have been affected by malnutrition or stunting factors. We have under 5 or pregnant mothers - to be able to support them with different knowledge in terms of what kind of food and what are the key issues of having a healthy baby, and nutrition plays a key factors in terms of supporting these - supporting the poor families, because cash itself is not enough, but also they need knowledge. Most of the time, they do not have the key factors in terms of improving their nutrition. They're often not aware there is something, so those are the kinds of issues that you need to go another level to support these families.

Tia Palermo  11:40 
Wow, that's a really powerful statistic, the fact that one in three children under the age of five are stunted. So this is a key sign of chronic malnutrition. And it's a really serious concern because malnutrition can impair cognitive development and stunt growth. And it can also really contribute to this intergenerational persistence of poverty. You mentioned babies, and I think it's important to know that a lot of stunting is determined in those first 1000 days of life between conception and age two. So you have been working quite a bit with a new program, a cash plus program for nutrition targeted to PSSN households. Can you tell us what this is called, and a little bit about this program?

Jennifer Matafu  12:35 
Yes, so we did a pilot program called Nourishing Life, or Stawisha Maisha. And the pilot was done in two areas, one in the Mainland in an area called Mbeya District, and then one in Zanzibar. That's another area. And the main objective is to promote and improve the infant and children feeding practices. And we were able to, during the course of one year, to get some key findings, and one of the findings that we noted in the end of project evaluation, the increased knowledge in terms of the choice of food feeding practices, for most of these families, like you said, 1000 days of breastfeeding - most of the people of this household didn't know that you have to breastfeed your baby for the next six months without any additional water or additional food. So that was well received. And also another thing with a very positive outcome during the pilot is that most of these people, especially mothers, they're illiterate. Most of them haven't gone to school, and they have less knowledge of basic issues, which maybe we take it for granted. So during the course of this pilot, we thought we saw that there was also a very good appetite for knowledge. And we saw also confidence increasing between the women groups. And also we saw that also men are interested to be good parents, taking care and ensure that nutrition foods will sort of be a part of their meal in the household.

Jennifer Matafu  12:35 
And I understand it's a story about a woman in the community. Can you tell us a little bit about what Stawisha Maisha is and how it's delivered?

Jennifer Matafu  14:41 
Yes, Stawisha Maisha, we call it, it's a peer group where you have a group of 12 to 15 women or caregivers who are part of the PSSN program. They come together, and then they have some different edutainment or different activities towards learning on the infant and young children feeding. One key activity was having this comic lady who her name was B. Stawisha, and she was part of the story whereby as a very key person in terms of educating, informing what kind of food she'd provide in her household, and what she had made a difference in terms of having her grandchildren with better meals. And also she has been a key player in the community in terms of providing some information about the choice of food they should have. So this was basically a storytelling, and everybody because it's a storytelling and there was some drama, the names of different actors, players within that community. Then it became very interesting for the group to sort of follow, and this was one of the activities, which was very well received. And everybody now, they tend to talk of B. Stawisha, and some of the names of the children, the grandchildren and some of the names within the community. The key issue is that she was, in terms of providing the right information, why you should eat eggs, why you should fully breastfeed for six months and additional food after six months. So that in itself, being given in a very comic way, and in a storytelling way is very important, especially for people who are illiterate, who cannot read, and they cannot write. So the visual and storytelling became very interesting, and most of them now, if you go to those areas, they could remember the story.

Tia Palermo  17:01 
That's really interesting. So for some of our listeners who aren't familiar with the term edutainment, it's basically an entertaining way to educate people. And it's part of one strategy for broader communication for development. And as you mentioned, it seems like it's been very successful for populations that maybe don't have very high literacy levels. And they're also having fun with it, it sounds like she's a comic character. And it gives chances for people to kind of get together and have fun, but also learning. So what is UNICEF and government hoping that Stawisha Maisha will achieve?

Jennifer Matafu  17:42 
Like I said, the end of the project review sort of recommended that it should scale up to the whole program area and all program areas, the whole country, of course, including both Mainland and Zanzibar. The aim is really to support the factor that, like you said, that if the child in the 1000 days missed basic nutrients, doesn't get breastfed, then the cognitive issues can be permanent, you cannot repair that. So we have an audience of the very poor, and we have like 300,000 children in the program under five. And if we can be able to reach them with the right messages. And in terms of comic, in terms of using different methodology like radio, I think we would contribute in a better way to minimize the kind of factors of malnutrition in these areas. And if also at the same time, is unintended positive effects, we can empower women in these areas, the whole country and the poor families, to bring more self efficacy/confidence into themselves to participate more. Activating the villages, calling social communities, I think that will be another level of of achieving some good results and for helping poor families not just be dependent, but also to take action in terms of the political economy in the area and also in terms of improving their own livelihood in their household. So the intention really is to reach out all the children in this program under five with their families and their caregivers with the right messages so that they can benefit from these messages and in a way contribute in reducing those cases of malnutrition. I think that would be a very good result for UNICEF.

Tia Palermo  19:51 
And you mentioned scaling up, so if I understand correctly, you had facilitators go into the villages to help deliver these messages when you did the pilot in Mbeya, in an area of Zanzibar. As this program is being scaled up to other parts of Tanzania, how is the delivery method changing?

Jennifer Matafu  20:15 
We are thinking, we learned one key lesson that most of the community is illiterate - they can't read and write. What will happen is, again, we'll continue the formation of the groups at the community level, and then we'll use radios as the methodology of delivering the storytelling, some of the messages to the groups. The groups will convene, and then they will have a radio program, at a specific time they'll play the program, and they will listen. And they will have some kind of discussion activities too, so that they can understand the messages being casted for them. They will also have that opportunity to influence the behavior of nutrition. How they, in terms of nutrition, infant and child feeding, the breastfeeding case. And also, if we can also create that social network within this poor community, to enable them to move, to be more engaged in community issues that will really be one call of UNICEF in terms of outreach, but then it's not about UNICEF, it's about helping the government, for them to be able to address the developmental issues and results they want to achieve within the social protection and nutrition because then they are complementing each other. But radio is going to be the mode of methodology in that community level. Groups will still remain as a medium so that there can be the interaction and discussion and also show social networking.

Tia Palermo  22:04 
When I hear you talk about this fascinating program, some of the themes that really stand out to me are how you and your colleagues have been learning and really interested in finding out what works and how and kind of really taking up that evidence in your next steps. And also how not only the learning and the evidence uptake, but also how you are looking to scale this program up and make it more sustainable. And what type of delivery modes can make it sustainable. I'm wondering if you have plans for more learning and evidence generation as you scale this up further?

Jennifer Matafu  22:42 
Yes. Out of the social protections, collecting evidence and data so that the lesson can be sort of disseminated/shared. And also they can influence policy and implementation in different levels. Yes, there's going to be monitoring - an evaluation component like this, given the scale, I think our country is going to be one of the few countries which we are scaling up in the whole country, not just in areas. So the evidence and data and lessons, which are going to be learned during the course of implementation are key, we have set aside specific evaluation on collecting the data during the implementation costs, because that can sort of help in so many level, not just in terms of the high institutional learning, but in terms of policy, and also government's strategic approach in terms of nutrition or mostly in other classes within the poor communities which are involved in the social safety network program. This is, I think, it's key. Otherwise, it would be such a waste if we just scale up and then you don't bring the lessons back to the policy level.

Tia Palermo  24:10 
It's really exciting to hear the dedication that your team has to evidence and learning and improving these programs. It's been so interesting to hear you talk about this today. Stawisha Maisha sounds like such an important and needed program that can really have a big effect on families in Tanzania, especially those who are most vulnerable to poverty and malnutrition. I've really appreciated you sharing your time and your expertise to talk to us today. Is there anything else you'd like to share with me and our listeners here at Buffalo HealthCast before we close?

Jennifer Matafu  24:50 
Just to emphasize that Stawisha Maisha is a social-behavioral change initiative and behavior is the key objective or term - changing behavior, influencing behavior is really key in terms of the whole implementation, just not supply of delivery, implementation. But behavior change will take a while. But I think that is one of the objectives of sort of scaling up to support and help influence both behavior at community household level, and also bring those lessons at national level, I think that would be a huge, big results, both to TASAF organization.  TASAF is the government agency which is implementing the social safety network PSSN. And we are supporting TASAF to be able to bring these results at the national or even regional level. So it's helping out UNICEF by supporting the government to be able to implement in an effective manner.

Tia Palermo  26:08 
Well, it sounds like you and your partners in government have your work cut out for you. But it sounds like you're also really passionate about this, and also taking into account learning and evidence and trying to make this program better and scale it up so it can help even more families. So, again, here at Buffalo HealthCast, we really appreciate you taking the time to talk to us today. This has been a really exciting conversation. And we just want to thank you. Thank you so much for being with us today.

Jennifer Matafu  26:40 
Thank you, Tia. It was good talking to you.

Outro  26:44 
This has been another episode of Buffalo HealthCast. Thank you to our guest, Jennifer Matafu, for taking the time to speak with us today. Nicole Klem is our Faculty Consultant. Sarah Robinson is our Production Assistant. Omar Brown is our Sound Editor. And our theme music was written and recorded by Sungmin Shin of the UB Music Department. My name is Tia Palermo, your cohost and writer for this week's episode. Thank you for listening and tune in next time to learn more about health equity in Buffalo, the US, and around the globe.

Saad Alasil  0:00 
Hello and welcome to Buffalo HealthCast, a podcast by students, faculty and staff of the University at Buffalo's School of Public Health and Health Professions, covering topics related to health equity here in Buffalo, around the US, and globally. We are your cohosts for this episode, Saad Alasil.

Kayla Giglia  0:22 
I'm Kayla Giglia.

Tiffany Mai  0:23 
I'm Tiffany Mai.

Saad Alasil  0:24 
This podcast comes following our participation at the Climate-Health Innovation Sprint, organized by the University at Buffalo's Office of Global Health Initiatives, for which our team won first place. The pitch that we did was to expand access and routes of the Niagara Frontier Transportation Authority, or NFTA, to lower levels of environmental pollution, and ensure equal access to transportation for all residents of Buffalo. Our guest today is Derek Nichols. He's the Associate Director for Sustainability, Division of Finance, and Administration at the University of Buffalo Sustainability. Thank you, Derek, for taking the time to be with us.

Derek Nichols  1:10 
Hey, it's a pleasure to be here everybody. Just a little bit about myself and my background. I am a University at Buffalo alum from the Masters of Urban Planning program. So I focused on community development and food systems there. And then right after school, I started working at Grassroots Gardens Western New York for about four years, helping neighborhoods build and steward community gardens and spaces in their neighborhoods. Then I've most recently started working at the University for - my six year anniversary is coming up in a couple of weeks here -where I focus on trying to change the culture of our campus to be more sustainable. It's not just an academic program, not just a student facing program, not an operational program. It's all of that. So I work in a very small office with just four people. So to work with 40,000 people in our community, campus community, it's a lot of work to try to change that culture. So we really rely on our connections and relationships that we have built across campus.

Saad Alasil  2:08 
Well, thank you, Derek, for that introduction, you guys do a great job. My first question to you; according to the 2020 census data, 67.5% of Buffalonians, who are 16 years of age and above commute to work by driving alone using their own cars, whereas only 11.3% of those workers use public transportation. Now, that's a lot of cars on the road. And I can only imagine what are the recent levels of air pollution in the city. So my question to you is what makes only a small percentage of people use public transportation here in Buffalo?

Derek Nichols  2:43 
It's a really interesting question. I think there are many different reasons. Some of them are institutional and foundational, and some of them are just personal. I think that when we look at Buffalo, when you look at its history, because of practices like urban renewal and creating highways, and creating city layouts that are meant for the car, it makes people - just an easier way to get around. It's convenient. We have low commute times to get across long distances from in our region. So having a car makes that easy. The public transportation system here isn't the best, and it takes a lot more time to use either a bus that connects to the metro rail to get to another bus. And sometimes the routes are not not very straightforward for commuters. So ease is one reason. Another reason is, I think, safety is a concern. So especially thinking about the winter, and this past winter, there was a lot of news stories about how plows were just plowing a bunch of snow and ice into bus shelters and people would have to wait in the streets for buses. And that's difficult for people, especially that have accessibility issues. And then just any commuter, waiting in the street is not an ideal place to be. So I think there's a lot of conditions that have - make it ideal or more optimal for people to use a car. There's a stigma about public transportation, there's a negative view on public transportation in general, from a lot of people. And the other thing is, too, that car ownership -  there's about 30% of our city that doesn't own a car. So that's the other flip side of this is there's a lot of barriers for those people that don't have a car to where they have to go.

Kayla Giglia  4:20 
Okay, so obviously being public health, we definitely are interested in the health effects of air pollution, which certainly impacts everyone, but it definitely does impact those who live in the cities and who drive in and out every day. So some of the issues, the health issues that come up according to NIH, is different respiratory diseases like asthma, emphysema, COPD, chronic bronchitis, various different cancers, like breast cancer, lung cancer, leukemia, non-Hodgkins lymphoma, the list goes on. And children who live near these highways are at even greater risk of developing these diseases, like asthma, at such a young age. So the health effects aren't even the only issue, there's also issues with sleep and increased noise congestion because they live so close to these highways. There are going to be cities near these roads. So who in the City of Buffalo is suffering the brunt of these health effects, and why?

Derek Nichols  5:07 
Buffalo being where it is, and being - literally I can see Canada from my neighborhood, when I'm taking a walk in my neighborhood. It's a huge international border with tons of transportation. So the Clean Air Coalition was an amazing organization here in Buffalo that does a lot of advocacy work on this topic. And they did a health study in the West Side of Buffalo where the Peace Bridge kind of lands in our city. And the Peace Bridge has about 5,000 trucks that cross across the bridge, pre-pandemic, every day, and then about 20,000 cars, so that's a lot of traffic, and there's a lot of diesel gas. And they found that there's 44 different chemicals in diesel gas exhaust fumes. So what that all has led to, is that they have found that about 45% of houses in the West Side neighborhood have at least one case of asthma. So that's, right there, the clear - pretty clear connection to traffic and health in one area of Buffalo. Back when I worked with Grassroots Gardens, when we started, when neighborhoods were finding vacant land to plant gardens on, we were always very concerned about high traffic areas for the pollution. People are out there gardening, they're right next to a busier street, or a busier highway even, that cuts through the city - that would be something we'd kind of help. We'd try to find a more optimal place for a neighborhood to start a garden on, just because we didn't want the gardeners are at risk for air pollution because of the traffic. And that's, you know, a lot of that was on the East Side too, when the Kensington Expressway was built, and the NY 33, of course, through that. So those are really two big areas of where you'll see the effects of air pollution. And of course, those neighborhoods - it's a huge environmental justice concern, because there are neighborhoods of black and brown people, and New Americans to our city. So typically, people who have been traditionally marginalized in our city in general, and a lot of times the answer is "just move." And people do not understand that's a very privileged answer to the problem. Because either if you own a house in that neighborhood, it's hard to sell it to somebody else, because they're gonna be facing the same burdens. Then you see that environmental cases throughout history, people are trapped in the homes that they own. And then the housing is just cheaper in a lot of these neighborhoods as well, because of these reasons.

Kayla Giglia  7:26 
And you mentioned organizations like the Clean Air Coalition and Grassroots Garden. What are these groups doing to address this issue?

Derek Nichols  7:33 
So the Clean Air Coalition, this is like one of their main missions, is to quantify and find areas of air pollution. So they do studies, they work very closely with the people who live in their neighborhoods rather than doing an external scientific study, which is really great. So it's a neighborhood empowerment model there. With Grassroots Gardens, their focus is on building neighborhood capacity and community work through gardening. So the environmental impacts of clean air is tangential to their work, but it's something that we were concerned about. GOBike Buffalo is another great organization that helps steward and build capacity on biking infrastructure, so to wean people off of cars, make our streets safer if you want to bike or walk or any sort of non-motorized vehicle. So those are really - GOBike Buffalo and Clean Air Coalition are the two organizations that are doing really great work on this issue specifically.

Kayla Giglia  8:32 
Thank you, that was really useful to know.

Tiffany Mai  8:33 
We heard in the recent news by the WGRZ television station that the NFTA has been cutting 8 of its 12 express routes starting in mid-February, and that means longer waits at night and on weekends. As Fillmore District Common Council Member, Mitch Nowakowski stated, as well as you, 30% of Buffalo residents do not own a vehicle, and they rely heavily on public transportation each day for their commute. The NFTA has made these temporary cuts because of staffing shortages, as well as low retention rates due to low wages. Now these service cuts have a lot of people who do not have cars and rely on buses to go to work, school, doctor's appointments, and also meeting their daily necessities, leading to most communities unserved to get around. One Buffalo Council Member even said that NFTA has downplayed the severity of these changes by being vague about the longer wait times. How do you think that the political system around the NFTA is being addressed within Buffalo? What I'm trying to say is, with the NFTA being so incorporated with how the City of Buffalo interacts on a day to day basis, how does the politics get around to advocating for a better public transportation system?

Derek Nichols  10:03 
When I look at public transit and who, especially with that, with the example of the NFTA cutting some of those lines, the late night and weekend routes, the second shift, third shift workers who utilize that, and those are usually lower paying jobs. So the fact that they're cutting routes, that for individuals who might even be more strapped, maybe have more pressure to use as an issue. When I look at transportation as a whole, and I'm gonna connect these two dots in a second, but when I look at transportation as a whole, it's one piece of the city's fabric and one piece of how we all function in our lives. When we look at public transit, a lot of that is public transportation needs to be accessible to everybody. And by cutting routes, and streamlining, or slimming down services, it's a big issue for a lot of the residents in our city. So the thing is, urban policy and urban planning can't be siloed. So it's more of a holistic, and needs to be looked at holistically. So my thought is that, yeah, public transportation is a tool to help alleviate poverty by getting people to where they need to go. And it's quick time to their jobs, so they're not spending time waiting, commuting to go to doctor's appointments or waiting to go to school even. So I feel, my thoughts on transportation planning in general and how the NFTA operates, that needs to be collaborative, and it needs to take into account other essential services like food systems, like energy, like housing, and it needs to be thought of completely and in an appropriate way for the city. That means that poverty is not a naturally occurring thing, right? It's the system that we are all living in has created poverty. It's for reasons that one individual can buy Twitter, while other people are waiting for a bus for three hours to get to work. So I think there's bigger systemic and structural changes that need to happen to alleviate, to kind of help fix priorities of our city.

Kayla Giglia  12:15 
That actually kind of ties into one of the other questions we had - just like static issues that tie into all these other issues, like energy resources. One policy that has been pretty bad is redlining. How has that impacted - you talked about neighborhoods like the West Side and the East Side - how does that impact where these highways are built, and the people who live in these neighborhoods?

Derek Nichols  12:34 
Yeah, well, redlining is very racist. And that has a huge, big history of that in the City of Buffalo. So, the East Side neighborhood in the Kensington-Humboldt Parkway was destroyed because of redlining, so an urban renewal. The combination of keeping people away from certain neighborhoods, and keeping people in certain neighborhoods, as well as demolishing neighborhoods and destroying urban fabric, and the urban fabric has basically allowed for things like highways to be built through neighborhoods, that have allowed for wealthier individuals and white individuals to leave the city, creating more of a concentration of disinvestment. So, did I answer some of your questions about redlining?

Kayla Giglia  13:18 
Yes.

Tiffany Mai  13:18 
So I'll ask a question. Do you think that restoring these routes and increasing staffing will solve the transportation problems in Buffalo?

Derek Nichols  13:26 
I think it will solve the problem for those individuals who rely on those routes. But I think it goes back to my earlier comments about looking at poverty and disinvestment as a whole, and changing how we distribute resources, how we build city policy, and build our neighborhoods here in Buffalo, and regionally too, because there's a job spatial mismatch. A lot of the people who work in our city go outside of our city to work. So they are really a cause for a collaborative effort network. And the Greater Buffalo Regional Transit Coalition is doing a lot of good work trying to make those connections too. So again, yes, those routes are very important for the livelihoods of the people who use them. There's a bigger picture to look at that we need to keep sight of as well.

Tiffany Mai  14:19 
Now, the transit sector is responsible for 1/4 of global greenhouse gas emissions. And as our population continues to grow, public transportation helps us solve our social, economic, and environmental challenges. The benefits of public transportation are immense, with decreased congestion emitting to better air and noise quality, transportation, reliability, and building a social ecosystem for our communities. Most recently, the NFTA was granted $4.8 million to replace their older buses for new lithium battery-operated electric vehicles. And they also introduced, just recently, their first electric bus. Now these buses will help eliminate up to 85 to 175 tons of greenhouse gases each year. We also see wages saved by taking public transportation with the fare of $2 for buses and trains, compared to the cost of vehicles and the increase in gas prices we see today. For example, just last year, gas prices were only $2.77 a gallon, and now it has doubled to $4.28 in November 2022. However, New Yorkers will have a chance to vote in a public referendum that will enact a billion dollars and more to electrify all buses, and install charging stations by 2035 through the Bond Act. Now, there's a lot of funding going around, so I will mention a few. With $31 million in federal funding, how do we improve and market public transportation in a car-cultured community? Improvements in bus routes, new bus mappings, and timing blocks for riders to easily visualize how to commute to areas they've never been before, additional bus shelters, in-app ticket purchases, and turnstiles, and electric buses and repairs, increased wages for all employees to improve retention rates, are just some of the few improvements made by the NFTA. The NFTA also serves up to 24 million people each year, and with the COVID-19 pandemic, many riders were reluctant or even discouraged to take public transportation because of the virus. However, the NFTA has worked hard to keep their riders safe by following COVID-19 protocols to disinfect and protect everyone, and reduce the spread of COVID-19. In addition to the recent shooting in Brooklyn, New York, the NFTA police ran a sweep to investigate all buses, trains and stations, and even installed 24-hour running cameras to protect our riders and employees, increasing the safety for the public of Buffalo. And one of the biggest services that the NFTA offers is their PAL, or paratransit services that serves all able-bodied in addition to the disabled, veterans, and seniors to expand their reach to a three mile radius supported by the $20 million funding request. Bottom line is, if we want the NFTA to expand, we need to start using it more. And with that in mind, we can only hope that the growing riderships can help indicate the growing economy we see in Erie County. My question to you is, what would a better mass transit system do to improve health equity in Buffalo?

Derek Nichols  17:38 
I think about this. This is another great question. I mean, we'd be revolutionary, right? I mean, that would change so much of how our city could function and work that I think the health benefit - there are a lot of health benefits. And I would kind of categorize them in three different ways. So there would be the physical health benefits, so less cars on the road, less air pollution, less, hopefully, less asthma rates, less car crashes, less, you know. Those are the physical benefits of this. And there's the mental benefits of this. So people who have to wait long hours to ride the further bus to come in cold weather, it's mentally taxing. The stress of trying to get to a doctor's appointment on time, getting to work on time, that's also a mental stressor for a lot of individuals that are already trying to balance so many other things, chaotic things in their lives. Not to mention during the pandemic, that's just one other thing that add on to that. And then just, you know, road rage in general, for people who are in cars; something we're all kind of guilty of, right? And then I think there's one of the biggest pictures of this, and I'm not in the health field, so I don't know if I going to use this term correctly, and there's probably a better term for it, but a preventative health measure. So, if we're thinking about the amount of greenhouse gas emissions that we are emitting in our commuting patterns, long term, it's changing our climate, and we know the effects of climate change are gonna have a negative impact on the people who are really 1) not the cause of climate change, and 2) are in the most vulnerable areas that will be hit hardest by climate change. So we've needed to start decreasing emissions for a long time, and right now we're almost at a mitigation level, at this point. So the long term health game here is that, we can prevent a drastically changing climate, and all the health impacts of disease, and heatstroke, and all of that that would be wrapped up in our changing climate too. So I think that's a big thing, in my eyes and sustainability world. So one of the biggest impacts of changing our transportation structure here. There's a PhD candidate in Columbia University, who has studied - he's kind of put a metric on the mortality rate, the correlation to mortality and greenhouse gas emissions. So he's found that if you emit roughly about 4 million metric tons of carbon dioxide equivalents, 4000 metric tons of carbon dioxide equivalent, that's responsible for about one life. And then in the next century of killing somebody, one person in the next century. So I was looking at UB's commuting, I help assess the greenhouse gas impact of UB. So I looked at the student, faculty and staff commuting for 2020. And this is the beginning of - there were couple of weeks of pandemic in there. And we emitted about 22,000 metric tons of carbon dioxide equivalent in that year, just from our commuting patterns. That has the potential to kill five people over the next century. And that was just one year of commuting patterns. So if you think about historically, what UB has emitted, and in a non-pandemic situation, and what it will emit, there are lives that we are responsible for for our university. So that's just an interesting perspective on how you can communicate the importance of decreasing your greenhouse gas impact, and a metric that I'll continue to use in our conversations with our office to really make it - I think it's much more tangible than like, all the ice caps are melting.

Saad Alasil  17:38 
Okay, Derek, well, perhaps is the last question that we have. Now, we're all talking about the greenhouse gas emissions, and reducing them is definitely a good thing to do. But what do you think are the implications of switching to electric vehicles? And for transportation to meet the all-electric fleet by 2035? I mean, will that solve the problem, basically, of air pollution, to switch entirely to electrical vehicles?

Derek Nichols  21:47 
No, it's definitely a good start. So it depends on, well, there are a couple of things. So just by switching to electric vehicles, there's a benefit to where the cars or vans or buses are driving, because they're not emitting anything. But still, we're producing electricity, right? And that energy has to come from somewhere. And that depends on where your grid is. And luckily, New York State has a fairly clean grid. It uses a lot of renewable energy, a lot of nuclear in there, there's a lot of hydro from Niagara Falls. So our grid, the electricity use isn't - there's a little bit of coal in there, I think it's about 4% of our energy comes from coal. But if you move to, I always throw South Dakota under the bus, but I feel like I need to do more research into that. But I feel like South Dakota really has a dirty grid. I mean, we should say something like West Virginia, I think that's probably pretty dirty too. Coal territory, where they're burning a lot of fossil fuels to generate electricity; that's still very polluted. So even though you're charging a bus, or charging an EV in West Virginia, the energy that you're getting from that grid is still dirty energy. There's a connection there. So that's some perspective into the power of electric vehicles. So for New York State, and New York State has goals to have our grid completely be renewable. It's definitely helpful.

Saad Alasil  23:09 
Absolutely, absolutely. So I mean, the thought here is that we should look beyond just using electrical vehicles, but to the power grid that actually powers these electrical vehicles. I mean, how clean the energy is there. Are there any other questions, guys?

Tiffany Mai  23:27 
Yeah, so beyond electric vehicles and better public transportation, what would more equitable cities and neighborhoods look like if we incorporate more bike lanes, downgrade highways, or even look for alternatives to powering our buses or things like that? Because I know the topic about nuclear energy might be in the picture after 2035 perhaps, and we've had a history of closing down nuclear powers because of safety reasons. But there are major implications to electric vehicles that are on a global scale, harming the environment, more so than just diesel because natural extraction of these minerals and products to build these electronic vehicles come at a cost, and it's not at our countries, but more so in countries where most of our resources come from, like third world countries, where the raw materials are coming from. How, would you say, beyond electric vehicles and better public transportation, would you implement for a more equitable city neighborhood, as well as a global agenda?

Derek Nichols  24:51 
There's so much to respond to there, and such a good question and so many things. You're basically asking me to solve the climate crisis in just that question, so a couple of things. Yes, in our work, one of the biggest tensions that we face and trying to mitigate and combat climate, our changing climate, is how quickly we need to move versus how equitable we need to be. And that goes to what you're saying about, like the extraction of the parts that go into our EVs that, hopefully are part of the solution. But then we know that there's a detriment to the places they are extracted from. The answer, of course, we have to be both, we have to be equitable and fast. And that's hard, and the world we live in does not operate like that at all, in any capacity. It doesn't move fast, and it's not equitable at all. So it's asking for humanity to do a lot. And just that question, we're talking about, I mean, we're ultimately talking about local transportation here, and I'm talking about changing the world. And also, you need to connect it to - I think more people need to be aware of just the decisions that they make on a day to day basis with their commuting patterns, and how much it really boils down to your politics, and how you need to be people in power to change systems that are inequitable and slow moving. And that also seems like a very defeatist - I used to be an idealist - it seems like a very hard thing to do. When that gets overwhelming for an individual who really cares about this, take a step back and think about the things that you can do that you have some control over. So you brought up bike lanes. We've seen some solutions being developed and implemented in the past couple of years. Having the option to do remote work helped; I don't need to travel 15 minutes to UB North Campus to stare at my computer all day, and then travel back and not talk to anybody, you know what I mean? So there are solutions that are right in front of our eyes to help combat some of this, that are very low hanging fruit. And then people have been advocating for better biking infrastructure for years, and it's been happening.  If only you guys could see what the bike lane situation was about 10 years, 10-15 years ago, when I was a student here. There was probably one bike lane. So now we have a network that connects and is ideal and perfect, we know what we're getting there. So I'm trying to now spin everything in a more positive light after you saw me dip down into a black hole for a second. But I mean, good work is happening, and th thing about Buffalo is there's a lot of good people doing this good work. It's all very inspiring. So I hope that - I don't really have a solid answer for the most ideal situation for our city and its transportation. But that's kind of the beauty of working in an advocacy and grassroots realm, is that we're all designing it together.

Tiffany Mai  27:53 
Yeah, thank you. And I just want to ask one question before Kayla goes. So we had a podcast Innovation Sprint, and one of the underlying questions about expanding public transportation is just the acceptance of it in suburban areas, because of the, you know, it ties into racism, but as well as just that immediate independent culture that goes around in our society - you know, car culture, basically. And so how do we reduce that stigma in suburban areas that are less accepting of public transportation? And I know that with the electric fleet that was introduced just last week, it's going through suburban areas for cleaner energy, attracting more riders within the community and such and so. Do you think that that is one way to go, or are there other ideas that can help expand that public transportation is for everyone, and exposure at a young age helps to bring that to light in our future generation?

Derek Nichols  29:09 
Now you're asking me to solve racism, which I don't know if I can't do that, either. But your last comment, it really made me - I had the privilege of being in an urban planning studio with Dr. Samina Raja, and she took our studio over to Germany for a week and a half, and we studied commuting patterns of schoolchildren and how they got to school. And it was very common to see a five year old on a subway pretty much by themselves -pretty self sufficient to get to where they needed to be, and that kind of connects to changing the culture of suburbia views, public transportation, I kind of talked about that a little earlier on without being super eloquent about it. But there's that stigma, like public transportation is unsafe. It's not meant for people like us, or people who are living in suburbia, we should be self-sufficient and have our cars and that's the American dream. I feel like generationally that is changing. So I think more young people want to see the benefits of public transportation. There's more people coming to our city from other areas who have public transportation and are very upset that there's not a good public transportation here. So I think that might have some effect moving forward. There's always been that unicorn or that white whale of extending the metro line to UB North Campus. And we've talked about that since I've been a student, and of course before that, too. So it seems like more and more funding is - there's always a news article saying, oh, funding is going to be dedicated to this, and there's there's studies going on. So I'm hopeful about that as well. And hopefully a metro rail to the airport. UB North Campus and the airport and downtown is now a much different place than it was 20 years ago, 30 years ago, at this point 40 years ago, there's much more going on downtown. I think suburban residents might appreciate a very quick connection to a much more lively and active downtown now. Once people start to see and realize that okay, public transportation isn't terrifying. I think that'd be helpful.

Kayla Giglia  31:21 
We talked on a global scale, and now that we're bringing it back to Buffalo, UB is doing a lot of work, like you said, with expanding the bike lanes. I know there's a lot of clubs on campus that are dedicated to sustainability. What else is your office at UB doing to try to solve this issue, specifically in Buffalo, or global, whatever you would like?

Derek Nichols  31:37 
Yeah, well, like I said in my introduction, my role is not super academic. It's not student facing, not all operations. But we are collaborators, and we build relationships. So we've, about 2-3 years ago, we updated our Climate Action Plan for our university. We were trying to get to carbon neutrality by 2030, which is about roughly seven years from now. And one of those strategies is electrifying our fleet and creating better ways to green our commutes. Because when we have three campuses: North, South, and then Downtown, so there's a lot of people coming and going constantly. So, you know, we are very fortunate to have buses already. Granted, they're dirty buses right now, but we are working on electrifying those. So just a little pulling back the veil on that. We have a contract with our busing, so it's going to be up soon. So that's why we can't snap our fingers and go right to electric because we are under a contract. So we're working on procuring an electric fleet for, hopefully, for our next contract. Where we can snap our fingers and have electric vehicles are departmental units. And it's been really, really great to see UB Mail, or UBIT, our campus dining and shops reached out to our office and was like, hey, we need a new delivery truck, or, hey, we need a new van, and these are the requirements we're looking for, but we want it to be EV, or we want it to be an EV. And they asked for our guidance and what the standard practices are out there. So people are already in that mindset already, where they want to transition. The university does have a policy for any new vehicle purchase; it does need to be an EV. But we were seeing that mentality beforehand. So we'll transition the vehicles that we do own quickly/slowly over to an electric vehicle. We are always installing new charging stations, so 16 new ones went up on South Campus this past year. More are always being added on North, so that infrastructure will always be updated. And we're going to need to constantly be up on that, because even I've noticed in my short time here (six years) there are more and more electric vehicles on campus and they seem to be always in use. And then we don't want to rely solely on just car transportation and bus transportation, we do want to make sure that biking is safe. And that's more of a regional collaboration, because - I have biked to work from my home in the City of Buffalo to UB North Campus, and it's not a fun time at all. You want to ride your bike and have a good time, but you'd have to go extremely out of your way to not get in any dangerous situations, or you're biking down Main Street and you're crossing your bike over the Kensington Expressway, which is a terrifying intersection, whether you're in a car or not. So there are things that UB doesn't - we don't have control over that intersection. We don't have control of a lot of physical spaces that are barriers for biking in general. But we do work with community groups closely, through our office. Among the 40,000 people who are in our university, a lot of them have connections to these institutions already or advocates in their own way. So that's also one of the great powers of the students here, is something that I've really come to enjoy in my time in sustainability. I've met students that are very vocal about where they think the world should be. And that can be either vocal at our office, and why aren't you doing these things, or just vocal in the community too, trying to make changes because they're really passionate about it and they get in a crisis mode, basically. So those are some things that that UB's doing, and that's my call to all the students who are listening to this, just keep making noise. Because there's me and my three coworkers that are trying to tell administration, Oh, here are the things we need to do. And they're just looking at us saying, Oh, the green team, of course they want that. But if the students are saying it, our faculty and staff are saying it, that's very powerful.

Saad Alasil  35:44 
Well, thank you, Derek, for sharing your thoughts and experience with us. It's been wonderful having you. We hope that the future of public transportation in Buffalo is more equitable, more accessible, and more affordable for everyone. Thank you for sharing your experience with us and we hope to see you again.

Derek Nichols  36:05 
My pleasure, anytime.

Outro  36:06 
This has been another episode of Buffalo HealthCast. Tune in next time to hear more about health equity in Buffalo, the US, and around the globe.

Intro  0:00 
Hello and welcome to Buffalo HealthCast, a podcast by students, faculty and staff of the University at Buffalo's School of Public Health and Health Professions. We are your cohosts Tia Palermo, Jessica Kruger, and Schuyler Lawson, and in this podcast, we cover topics related to health equity here in Buffalo, around the US and globally. In this first semester of the podcast, we're taking a deeper look at racism and health. We'll be talking to experts around the US, as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population health and wellbeing. You'll hear from practitioners, researchers, students and faculty from other universities who have made positive changes to improve health equity and inclusion.

Schuyler Lawson  0:47 
Hello everyone, and welcome to another episode of Buffalo HealthCast, the University at Buffalo's premier public health podcast. I'm your host, Schuyler Lawson, a second-year PhD student in the Department of Community Health and Health Behavior. With us today is Dr. R. Lorraine Collins, the Associate Dean for Research and tenured professor in the Department of Community Health and Health Behavior in the University at Buffalo's School of Public Health and Health Professions. Thank you very much for taking the time to speak with us today.

Dr. R. Lorraine Collins  1:12 
Thank you for inviting me.

Schuyler Lawson  1:13 
You're welcome. So first off, tell us a little about yourself.

Dr. R. Lorraine Collins  1:19 
It's a complicated story. So from birth to now, I was born in Jamaica, I emigrated to Canada when I was nine years old, and grew up there and went to undergraduate university there. Graduated from McGill University with a Bachelor's in Psychology. I moved to the US in order to pursue behavioral training in psychology and went to Rutgers. After Rutgers, or at least as part of my PhD, I went to University of Washington in Seattle, where I did a one-year internship. And following that I wanted to stay in Seattle, and I landed a two-year postdoctoral training position in the Department of Psychology at U-Dub, as we call it. Subsequently, I came back east and started my academic career in the SUNY system at Stony Brook in their Department of Psychology. I am grateful for the fact that somebody from Buffalo at the Research Institute on Addictions, the new director, Howard Blane, called me literally out of the blue to ask if I might be interested in a full time research position. And I'm like, full time research? I'm there! Anyway, I came, gave a talk, saw a little bit of the city. Wasn't sure, so I accepted the position. But then I maintained a one-year position continuing at Stony Brook because they didn't want me to go, especially because I landed my first grant, just there and decided after a year at RIA that I really liked Buffalo, so I've been in Buffalo ever since. That's a long story.

Schuyler Lawson  3:12 
It is, but you summarized it pretty well, so I'm pretty sure there are more rich details there. But I think that's a pretty good summary of it.

Dr. R. Lorraine Collins  3:21 
You can follow up on whatever you'd like.

Schuyler Lawson  3:23 
So how long have you been in Buffalo?

Dr. R. Lorraine Collins  3:25  
I came to Buffalo in the late 80s, and didn't think I would be in Buffalo for my entire career. But among other things, I met and married here, and have a daughter who was born in Buffalo. And that among other things, the satisfaction I had in my career while at Buffalo kept me here, and at this point, I'm just happy to continue living in Buffalo. It's a wonderful city and has a lot of amenities that I don't know that everyone appreciates. Great parks, good restaurant culture, proximity to the outdoors. There's just a lot going on in Buffalo.

Schuyler Lawson  4:13 
As a transplant, I can also agree to that sentiment.

Dr. R. Lorraine Collins  4:17 
Yep.

Schuyler Lawson  4:17  
So getting back to your trajectory that landed you here, tell us a bit about your research background.

Dr. R. Lorraine Collins  4:25 
So at Rutgers, I actually did my dissertation, behavioral intervention related to obesity. But when I got to my postdoc, I switched from obesity to alcohol research. And part of this switch had to do with the fact that the overall issue in which I was interested was self control. And the interesting thing about eating is you really have to exhibit some kind of self control because you have to eat, some people, three meals a day. With alcohol, it was different because alcohol is not essential the way food is essential. But still, there were similar issues with regard to self control. And so making that transition actually went, I think, pretty smoothly. I mean, I ended up doing a lot of reading at the start of my postdoc, but I was able to catch up relatively quickly, because the underlying issues and many of the theories overlapped. And so it worked out well.

Schuyler Lawson  5:41 
Okay, and I guess what led to the transition to cannabis?

Dr. R. Lorraine Collins  5:47 
So that happened in a study that I ran in Buffalo. We had gotten a grant to look at malt liquor use. And the reason I was interested in it is because the stereotype of who uses malt liquor is that it's an African American male. And I'm not fond of stereotypes, and so I wanted to look into what's going on there. And there was a special RFA from the NIH, because they were also interested. What had happened is, each year the heads of Addictions Institute, well, all the institute's in NIH, go in front of Congress, and a congress person asked the then head of NIAAA, "You know, there's a lot of malt liquor in my community, what are you doing about that?" And he literally did not have an answer, and so they scrambled to provide an answer. So anyway, got this grant, applied, and went through all the peer review and what have you. And in it, we conducted a survey, in which we tried to recruit people who were regular malt liquor drinkers, and I give my staff an incredible amount of credit. I mean, they were at Thursday in the Square, they were all over Buffalo, recruiting folks who drank malt liquor. And we ended up with a sample of over 600 people, which was just, I think blew my mind and all of our minds. And the stereotype is not true. Among the folks who responded to our survey, were kind of the range of ethnicities, but definitely a sizable number of people who were from European backgrounds, as well as African, as well as you know, you name it. So given all of that, we were able to publish a couple of papers making that point. But one of the intriguing findings, unexpected for me, anyway, was that half of our sample also reported regular cannabis use. And we always ask about use of a wide range of substances, and usually, you have a sprinkling here and there, but for half of our 600 participants, who were predominantly male, to report regular cannabis use was very intriguing. And so I said to my staff, we got to follow up on this, because this is new. I'm trying to think of when that work was published, it was probably early 90s. And so that's when we started to pursue cannabis research. And at that time, there was hardly any.

Schuyler Lawson  8:45 
This is pre-medical cannabis?

Dr. R. Lorraine Collins  8:48  
Oh yes, it was pre-medical cannabis. And there were kind of reports of cannabis use, kind of often linked to other illicit drugs, but an out and out study of just what's going on with cannabis was not that common.

Schuyler Lawson  9:11 
Okay, and since conducting that study, was there any follow-up studies you did involving cannabis specifically?

Dr. R. Lorraine Collins  9:20 
I've done some studies, again, funded by NIH. I did one where we looked at behavioral economic demand for cannabis, and that's kind of an experimental procedure where we vary the price of the product and ask people to respond to those differences in price by telling us how much they would purchase.

Schuyler Lawson  9:46 
This is hypothetical?

Dr. R. Lorraine Collins  9:48 
It is all hypothetical, done in a lab, and what we found is that cannabis is like every other product, which is as prices go up, purchases go down. We also found, and I don't have the numbers in my mind, but we also found that there was a price at which people would essentially lessen their purchases. Well, I won't say a number because I know I'll be wrong. But anyway, that, I'm proud to say, was the first experimental behavioral economics study of cannabis purchasing and demand curves and characteristics related to cannabis. Others have continued in that work. There had been work done on alcohol for a number of years. But we were the first with cannabis. I probably, most recently, I did a pilot study that we're hoping will turn into a bigger grant, but did a pilot study for cannabis users where we developed a smartphone app. So folks came into Kimball, they met with a therapist for about an hour. There were four sessions where they learned all sorts of behavioral techniques. And then they interacted with the app, learning tips, kind of being able to reinforce what had happened in the session, and providing us with self reports that are related to another innovation with which I've contributed, and that is ecological momentary assessment of substance use. So that research started with tobacco smoking. Saul Shiffman, at University of Pittsburgh, was the innovator. I saw Saul give a talk and I said to him, we have to apply that to alcohol. And so after some efforts, we got funding to do that. Just so you know, the reviewers at NIH, were not convinced that people could self report on their alcohol use if they had been drinking. So we have to do studies to make that case. And what ecological momentary assessment involves is, we randomly prompt them, usually three to four times a day just to find out, Hey, what's going on? How are you feeling? Who are you with? What are your plans? What activities? Where are you located - home, driving? And then what we do is, before they drink, and this is after some training, we ask them to report on what's going on - similar questions, but then we might also ask about, are they craving? Do they have specific amounts that they plan to consume during that party or that dinner? And then after the episode has ended, we asked them, how are they feeling? How intoxicated are they? What's their mood, plans to continue drinking, that sort of thing. So we did that for a few years. And again, an innovation of mine was to move ecological momentary assessment to cell phones. Prior to that, we had used what are called personal digital assistants, and they were fraught with problems. People were carrying their phones and this other device, the data that they provided was loaded on the device, which sometimes would lead to glitches with data, storage, and so forth. So we did, again, proud to say, the first cell phone study involving ecological momentary assessment for anything. That was published in 2003. So you can tell we've come a long way when it comes to smartphones now. So anyway, we did a study where we had people coming in for sessions using our smartphone app during the rest of the week, and providing us with ecological momentary assessment data. One of the groups, so we had two groups. One was what I just described, and the second group, just because of some other work I had done looking at physical activity and substance use, we included a physical activity component where we recommended three free fitness apps. We kind of used multiple apps and found three that we thought were reasonable. And long story short, at six months, although both groups had reduced their cannabis consumption, the group that included the physical activity had reduced it more so, significantly more so. Which kind of reinforced the idea that was in the literature that physical activity was actually a useful component in behavioral programs to lessen substance use. It's been done in smoking and alcohol, and again, we showed it in cannabis, and we were one of the first. Boy, talking about this, I'm like, Whoa! I have fun doing research. I have fun thinking about things and applying ideas from one area to another. So I suppose that's how it's come.

Schuyler Lawson  15:27 
Another interesting part of your trajectory is that you actually had a stint in the public policy realm. In 2018, you were part of a working group created by then Governor Andrew Cuomo, that was tasked with drafting legislation on how to regulate cannabis in New York State. What did your work entail?

Dr. R. Lorraine Collins  15:45 
So, it was about a six-month very intense experience, intense in the sense that we were trying to get a lot done in a relatively short time. It was a wide ranging group of professionals. One of the people I was kind of surprised to see in the room, although now I understand why was the Department of Agriculture. Like, Oh, why would they be there, but guess what, you have to cultivate cannabis, so they were there. Obviously, physicians, public health, the Sheriff's office and State Police. So kind of judicial folks, a couple of community-oriented prevention people, and then the New York State office that focuses on substance abuse treatment, OASAS, they had representation. And we met mostly in New York City. I can remember at least one meeting in Albany, and we would discuss all the issues that we thought were relevant to New York's moving to adult recreational cannabis access. And I say adult because the age of 21 was kind of our marker. One good thing for us is that other states had moved into recreational cannabis well ahead of us. I think another useful thing was that New York State had a medicinal cannabis program, and so we could learn from that, in terms of what parameters might be useful, who might be involved, that sort of thing. In the end, we made - Oh, I should mention, we also as a group, there were 17 community sessions where, not all of the group, but members of the group attended. We did not participate, but we attended and listened to testimonials and other statements from folks who are on both sides of the recreational cannabis issue, and I attended two held in this area and it was very interesting. A lot of the people who made statements were medicinal cannabis users. And they supported recreational cannabis in certain ways. But I think everyone expressed, well, no, I shouldn't say everyone, many expressed concerns about what recreational cannabis might mean. Would it mean lower prices for medicinal? They were all for that. Many parents and prevention types were concerned about kids getting access in upstate. There were folks who were farmers, or in areas where they thought they might want to grow cannabis. And so folks in those rural areas, who often are concerned about jobs, and just being able to survive and make a living, they were keen, so it was quite a diverse group. Each session lasted a couple of hours. And in that time, I think each person had about two minutes. There were transcripts and so forth, but it really gave us a feel for how the residents and citizens of New York felt about this issue. And those community listening sessions were everywhere from New York City to obviously Western New York, all of Central New York and as far north as the Canadian border, so we covered a lot of territory.

Schuyler Lawson  19:47 
A pretty broad range of New Yorkers.

Dr. R. Lorraine Collins  19:49  
Yeah.

Schuyler Lawson  19:50 
So in light of your contributions to the working group, what are your thoughts about how New York State rolled out its recreational cannabis? Like legalization?

Dr. R. Lorraine Collins  20:01 
So what everyone has to understand is it's not rolled out yet, we're still in the implementation phase. The law was passed in March of 2021, actually just about a year ago, because it was March 31. It's a very complicated bill, and that's probably going to mean hiccups along the way. I think New York had the right idea in terms of having this working group listening to its citizens, and really trying to put a lot of limitations in place so that it wasn't just a wild and crazy rollout the way we've seen in other states, some other states. So all of that is to the good. One of the things that I advocated for, and I was not alone in this, is that day the working group started to meet, given that we were looking at this issue, we should start public health education. We should have, just like we have with COVID, we should have public health ads that talk about 'New York is considering this, and here's what you need to know.' And we should be doing pretty wide ranging assessments of current use patterns, especially in high risk groups like young adults. To my knowledge, that has not happened. And we are in kind of this rush now to implement and I still haven't seen a single public health message anywhere that talks about the fact that recreational cannabis is coming, what it might mean, how to approach it, what the products are, how it will help New Yorkers to know that they're using safe and well regulated products, the goal of it. I mean, the goal is to kind of move people away from the illegal market to the legal market where there are, I think, a lot of safety procedures and licensing requirements in place. The illegal market is wild, and I don't think people understand that. I mean, you can cut cannabis with so many other scary drugs like fentanyl, and people don't know it, and they smoke it, and the next thing you know, we have an opiate overdose. So I'm all for the regulation, which is why I participated in the New York working group. I personally would like to see federal regulation so that we don't have the patchwork that we currently have. And I also, as a researcher, would like to see the removal of constraints on access to cannabis. So the big one, as everyone probably knows, is that the Drug Enforcement Agency, the DEA designated cannabis as schedule I, which means it's in the same class as heroin, it's designated as not having any medicinal properties, which we know is not true. I participated, the year before New York State, I participated in a national academies review of the health effects of cannabis. And although the evidence wasn't great in a number of areas, there were areas such as chronic pain, where there was strong evidence and so we need to find out more. And I'm particularly concerned because the advocates for medicinal cannabis and our local state legislatures and various other groups are presenting medicinal cannabis as if it's a panacea. I mean, there's almost no disorder that's not on a list somewhere of disorders that can be helped by cannabis. And it's just that we don't have research evidence to support that.

Schuyler Lawson  24:15 
Do you know if any of the recreational cannabis legislation will protect against that type of marketing that sort of touts cannabis as being a cure all?

Dr. R. Lorraine Collins  24:26 
So the law does include regulations about marketing. Here's my concern. The current guidelines literally say for New York State, that a practitioner, and there's a relatively small list of practitioners right now, but let's say physicians, physician's assistants, I think it's gone to nurses, dentists, their health professionals, that they can prescribe cannabis for any disorder, "they believe" it can help. Belief is not science. And to me, to have that language is reinforcing the notion that it can treat everything when we know it cannot. And it also leaves the field wide wide open to, for want of a better word, charlatans and snake oil salesmen who can say, Well, I believe this is going to help you, and sell whatever the product. It's just not good.

Schuyler Lawson  25:40  
In that review for the National Academy of Science, was there any evidence that looked at the effect of cannabis on serious mental illnesses such as schizophrenia?

Dr. R. Lorraine Collins  25:52  
Well, that is one of the findings that we reviewed, and I teach a cannabis course. And I mentioned that in the course, and students are always intrigued by it. But yes, people who have a family history or personal history of mental health problems, especially if it involves hallucinations and other kinds of psychotic symptoms, should not use cannabis. It's as simple as that. It seems to exacerbate their symptoms. And although there are, to my knowledge, no deaths that are directly linked to using highly potent cannabis, there definitely are folks who had to be hospitalized because of psychotic episodes, linked to using highly potent cannabis or just not realizing how much they were using, and then not being able to manage the cognitive and physiological changes that they experienced.

Schuyler Lawson  26:56  
I thought about that, because you described the arbitrariness of how practitioners can just prescribe medicinal cannabis to mix with whichever condition they deem requires it, and depending on who it is, and they don't have to have a knowledge of the patient's mental health history, it could be, potentially, a public health issue.

Dr. R. Lorraine Collins  27:18 
It's a huge public health issue, and even more disturbing, the way the medicinal cannabis works in New York, it's not a direct prescription. So the health professional can essentially write a script that says, this person could benefit from using cannabis. That's it, they don't really specify anything. Potency, mode, they just make a general statement. That patient then goes to an outlet that provides medicinal cannabis. And I will say New York State has done a really good job of regulating that. But anyway, they go and then it's the people at that - it's not exactly a retailer, but at that distributor dispensary, I think, is probably the right word. It's up to the staff at that dispensary to choose what the person should try or should use. And I worry about what kind of training those people get. In New York State, a pharmacist needs to be involved. But it's still kind of scary, unknown, what they might get for their so called disorder. One of the things we learned...So that National Academies Report was published in 2017. It's still being downloaded at a fair clip, because it's over 400 pages long and has a ton of information. And we've heard through the grapevine that there are dispensaries that use that to help their staff to train. So I'm pleased to hear that it's being put to that kind of use. But there's nothing in that report that's prescriptive. It's just, you know, we review the literature and here's what we found, and this has strong and this has weak. So I don't know that, although it's a great starting point, I don't know that some of the people who work in these dispensaries, other than the, "Oh, if you use the sativa bud, it will help you with...", or "If you use the indica tincture, it will..." I just don't know the basis for some of the recommendations. And then, although we probably don't have time to get into it, there's a huge, huge, huge proliferation of CBD products. Those don't have to occur in a dispensary. You can buy CBD at Wegmans. But that's another completely unregulated space, where because it's not officially a supplement, lots of claims are being made, and the Food and Drug Administration has not really gotten in there to regulate.

Schuyler Lawson  30:25  
Okay, so it's the wild, wild west when it comes to weed.

Dr. R. Lorraine Collins  30:28  
It's wild, wild everywhere.

Schuyler Lawson  30:32 
Okay, so getting back to recreational, how do you think the New York State's recreational cannabis approach compares to other states that have done similar legislation?

Dr. R. Lorraine Collins  30:42 
So New York did a wise thing in trying to learn from best practices and failures in other states, and I think because of that, our regulations are pretty decent. Again, I still don't know what's going to happen with implementation, because that's a work in progress. If we can implement in a way that addresses some of the issues that were raised in that working group and some of the issues that continue to exist, then I think New York will be doing a pretty good job. What I worry about is the legislature, the fact that even people who've been appointed to some of these committees and boards to regulate cannabis, don't know much about cannabis. You know, in teaching that cannabis course, one of the things we do is to break down how complicated a plant we're dealing with. And everybody doesn't understand that marijuana is not marijuana, is not marijuana. It's hundreds of different products. It's hundreds of different interactions in the body. It's very complicated in ways that, for example, alcohol is pretty straightforward. How do most people use alcohol? They drink, end of story. How do people use cannabis? They smoke it, they vape it, they drink it, they put it on their skin, they eat it in gummies and brownies. There's so many complicating factors. And I'm not sure that that's as well understood as it should be.

Schuyler Lawson  32:34  
I guess, what would you say are some of the pitfalls that other states before New York experienced in their recreational cannabis legalization?

Dr. R. Lorraine Collins  32:43 
Oh, wow. Where do we begin? A big one is marketing. There are states - Nevada comes to mind - where cannabis products are labeled and marketed to look like food products, to look like candy. They're plays on names of legitimate products that are given to cannabis products. The wrappings are colorful and flashy. And it really is just completely unregulated marketing. There are billboards, there are two for one sales. So that's a huge, huge problem that I don't think we'll have in New York. Potency's another one. I'm not sure what the upper level of potency will be in New York, but I know that there are states, again Nevada comes to mind, where you can buy concentrate that's 90% THC. Well, that's not a good thing. 90% THC is setting you up for psychotic episodes and some of the other problems that we know can occur. So those are two, I think, really good ones. There's a lot of regulation of the cultivation of cannabis, the processing of it, the retail outlets that not many, well, some states failed to do or now are backtracking to try to do. We recommended no vertical integration of the cannabis industry. So if you grow it, and process it, then you can't own the retail outlets. Because when you own all of that, that's called vertical integration. And what it means is that companies, as we call them, Big Marijuana, they can come in and do what Big Tobacco did. And so New York is trying to lessen the occurrence of that kind of integration. New York does have a social justice component that I hope will work. We just heard a few weeks ago that the governor okayed cultivation licenses, and they had to do that because the planting season is about to begin, and if they had waited, that would have been missed. And you want to have product for the likely opening of retail outlets in 2023. So anyway, in applying for cultivation license, one of the things that companies have to do is to include kind of an internship training component, where folks who have not been in the industry, but are interested in coming into the industry, and I think there's a provision for folks from disadvantaged backgrounds or backgrounds that have suffered as a result of New York drug laws, as well as women and other groups that have not fully participated in the industry, can start to learn. And so if all of that comes into play, it will help.

Schuyler Lawson  36:09 
Yeah, that actually got into my next question. So the War on Drugs has disproportionately impacted communities of color, particularly African Americans, with respect to experiencing serious legal consequences for possession and sale of small quantities of cannabis. So what has New York State done to address the social justice issue of dispensaries selling a product that not too long ago contributed to the disproportionate arrests of New Yorkers of color? I know you mentioned having priority for underrepresented groups for licenses, but are there other policies that have been proposed as well?

Dr. R. Lorraine Collins  36:41 
So one of the things that happened is that New York reiterated in 2019, a decriminalization law that had first been passed, I think in the late 70s. But anyway, there had been decriminalization of cannabis in New York, and it went nowhere. No one paid attention, I'm not sure of the details of the law. In 2019, a new version of that law was passed. And as a function of that law, having smaller amounts of cannabis is no longer a felony, it's more something that you get a ticket for. And the limit is less than two ounces of flower, which is the law, which is a lot because it doesn't weigh that much. So that has helped. And related to that, there has begun and continues to be process of expunging laws, or at least people who suffered from laws where they were arrested for having on their person or having in their possession, small amounts of cannabis. The last I looked at the data, New York has expunged about 200,000 records. There's another 200,000 to go. And what expungement means is that their arrest for cannabis gets removed from the public. It's no longer accessible to landlords or employers or really most entities, in some cases, it just is gone. There's a difference between just possession and for example, selling larger amounts or committing a crime where gun is involved, those will continue. So expungement is important because now that the records have been expunged, there are people, many of them, most of them African American men, who can apply for student loan, who can live in public housing, who can apply for jobs and so forth. And so that provides an opportunity for them to get on with their lives and not be hampered by the burden of being caught once with, you know, three ounces of cannabis. So that's really, I think, very, very good. There are also provisions where licenses, I'm thinking it's 40% of licenses, will go to folks from communities, often African American communities where there was a disproportionate negative effect from things like stop and frisk policies, where a lot of African American men were kind of caught up in police raids and hauled off to jail. So if we do that, that all sounds good. I worry about how that will work. I mean, we know that in construction and in other areas, there are firms that are minority headed, but when you kind of look deeper, minorities are not fully engaged in reaping the benefits. So that's something that I think we have to keep an eye on. The other thing I worry about is retail licensing that predominates in lower SES, or minority communities. The situation with liquor licenses in New York is an abomination, it's criminal. You can go to the east side of Buffalo and find a corner where you've got three alcohol outlets, there's a liquor store, there's a bar, and there's a corner store that sells alcohol, and you just kind of walk 20 feet and you go from one to the other. That's not a good thing. And if we do retail licensing of cannabis, the way we've done retail licensing of alcohol, we're gonna end up in a similar situation. Now there was an opportunity for communities to opt in or out of retail outlets, as well as kind of social use clubs. And that's been interesting. And I don't understand it all. But you know, you can have villages within towns saying no, but then the town's saying yes. And so, I did a piece on this in one of my lectures, and Hamburg comes to mine, in this area. So the village of Hamburg said no, but the town of Hamburg said yes, something like that.

Schuyler Lawson  41:36 
Does that supersede what the village declared?

Dr. R. Lorraine Collins  41:42  
I don't know, I've never understood how New York is organized. Many people don't. It's one of the most convoluted that I'm aware of, in the entire country. And so anyway, we have this opt in/opt out feature and surprise, surprise, higher SES communities, or communities that want to maintain "their traditional lifestyles" and kind of sense of selves are opting out. The opt ins are motivated in a lot of ways by tax benefits that they hope will come, and some by jobs. Although when you come down to it, it's probably more the taxes than the jobs. But anyway, it's going to be interesting to see what happens with all of this licensing, because it could go really well. Or it could be a disaster.

Schuyler Lawson  42:46 
So speaking of taxes, have there been any talk about where the recreational cannabis tax revenues are going to be put towards?

Dr. R. Lorraine Collins  42:54 
Oh, of course, a sizeable proportion. And again, I don't want to quote percentages, but I'm thinking 40 to 50(%) of the tax revenues and benefits are to go to disadvantaged communities, or communities that have disproportionately suffered as a result of the past drug laws. I'm not sure how that gets handled. Does it go to City Hall? Does it go to businesses? I'm not sure how that will be apportioned. One of the drivers of the social justice components of this law is Crystal Peoples-Stokes, who is from Buffalo, and who really, over many years worked hard to get cannabis regulation in New York State. And she is very purposefully driven to make sure that communities will receive benefits rather than harms. And so I'm thinking with her keeping an eye on things, that it could help, but so many details have to be worked out. And some of them we really won't know the consequences until after they're in play. And then the challenge will be, how do we fix that? How do we fix the problems? What kind of tweaks or out note changes do we need to make?

Schuyler Lawson  44:31 
Yeah, so it's gonna be an ongoing project, it seems.

Dr. R. Lorraine Collins  44:34 
For a few years, yes.

Schuyler Lawson  44:35 
So from a scientific perspective, what would you say are the advantages and disadvantages of recreational cannabis legalization?

Dr. R. Lorraine Collins  44:45 
So what I've mentioned before is safety. Kind of knowing the product that you're using. I mean, if a product says 10% THC, and we take it to a lab, the lab should tell us Oh, it's 10% THC. Right now, in some states, the label could say 10%, and the lab could say zero, or the lab could say 30. I mean, people don't really know what they're using, and I think it's important that people know. Moving people away from the illegal market is, I think, really important, not just from the perspective of generating taxes, but just the elements that benefit from that market are not elements that we want to support. So I think that that's really good and useful. The other thing to understand, the harms of alcohol, in many areas are probably worse than the harms from cannabis. It's kind of strange, that other than that blip of prohibition, alcohol has been readily available for centuries, and cannabis has not. So that kind of makes some sense.

Schuyler Lawson  46:03 
Yeah. I suppose I would also put tobacco in a similar sort of situation to this illegal product that's caused quite a bit of harm.

Dr. R. Lorraine Collins  46:11 
Well, the interesting thing about tobacco is, I'm not aware of any benefits. It's fully harmful. With cannabis, we've talked about medicinal benefits, and it really does seem less prone to egregious negative consequences than alcohol for sure.

Schuyler Lawson  46:37  
So before we conclude our interview, is there anything else you'd like to share with our listeners?

Dr. R. Lorraine Collins  46:43 
I think it's really important to advocate for public health education. I continue to be disappointed that that is not happening. And I think it's important to advocate for the removal of cannabis from Schedule I DEA designation because, until that happens, research is going to be stymied. And I think that it's important to learn from best practices elsewhere. So in the marketing realm, for example, Canada, all plain packaging, no billboards or marketing. You go into a store retail outlet, and it's very, very austere, as compared to walking into an outlet that looks like you're in a Vegas casino. So they're best practices, not only among other states in the US, but other countries. And we might want to learn from them as well.

Schuyler Lawson  47:43  
All right, well, thank you again for taking the time to be on our podcast. We hope to have you on again to discuss future issues, as the cannabis situation in New York is, like I said, it's going to be constantly evolving. So is there a way that our listeners can learn more about your cannabis research?

Dr. R. Lorraine Collins  47:58  
I have a web page. It's under CHHB (Community Health and Health Behavior). I do have a web page. I suppose you could do a search for my name.

Schuyler Lawson  48:10  
Yep, for Dr. R. Lorraine Collins, and also probably Google Scholar, to type in your name.

Dr. R. Lorraine Collins  48:17  
Yeah, my name gets weird on some search engines because I use a first initial, I will just caution that, but yes. If you do, Collins probably stuff will pop up. So thank you very much, Schuyler, this was interesting. I tried to pack a lot in - I hope it isn't overwhelming. But this is such an important and timely topic. I'm glad that you chose to focus on it with me or with others, because there are a lot of folks at UB doing cannabis research.

Schuyler Lawson  48:51 
Thank you. Thank you. Thank you again for being a part of the podcast and providing this valuable information on a very complicated topic.

Dr. R. Lorraine Collins  49:02 
My pleasure.

Schuyler Lawson  49:03 
You're welcome, and I'm Schuyler Lawson, and thanks for listening to another episode of Buffalo HealthCast. Take care and be well.

Outro  49:10 
This has been another episode of Buffalo HealthCast. Tune in next time to hear more about health equity in Buffalo, the US and around the globe.

Intro  0:00 
Hello and welcome to Buffalo HealthCast, a podcast by students, faculty, and staff of the University at Buffalo's School of Public Health and Health Professions. We are your cohosts, Tia Palermo, Jessica Kruger, and Schuyler Lawson, and in this podcast, we cover topics related to health equity here in Buffalo, around the US, and globally. In this first semester of the podcast, we're taking a deeper look at racism and health. We'll be talking to experts around the US, as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population health and wellbeing. You'll hear from practitioners, researchers, students and faculty from other universities who have made positive changes to improve health equity and inclusion.

Schuyler Lawson  0:47 
Alright. Hello, everyone and welcome to another episode of Buffalo HealthCast, the University at Buffalo's premier public health podcast. I'm your host, Schuyler Lawson, a second year PhD student in the Department of Community Health and Health Behavior. With us today is Dr. Monica Webb-Hooper, the Deputy Director of the National Institute on Minority Health and Health Disparities. Thank you very much for your time to speak with us today.

Dr. Monica Webb-Hooper  1:08 
Absolutely, happy to be here.

Schuyler Lawson  1:09 
Alright, so I'll begin by having you tell us about yourself and a little about your own education background too.

Dr. Monica Webb-Hooper  1:16 
Sure. Well, I am originally from South Florida, from Miami, Florida. And I attended undergrad at the University of Miami in Coral Gables, Florida. And then I earned a PhD in clinical health psychology from the University of South Florida in Tampa, in the Moffitt Cancer Center. And then I completed a clinical internship in medical psychology at the University of Florida. And after that, I had faculty positions. My first one was at Syracuse University. Then I returned home and I was at the University of Miami as a faculty member in the Department of Psychology. And before I joined NIH, I was at Case Western Reserve University, where I directed an Office of Cancer Disparities Research, in addition to being a professor.

Schuyler Lawson  2:07 
Seems like you have quite the illustrious background, and that kind of segues into a question about NIH. As the Deputy Director of the National Institute on Minority Health and Health Disparities, what are your work duties?

Dr. Monica Webb-Hooper  2:22 
It's an interesting question, what my work duties are, because every day looks a little bit different, which I think keeps it fun. But if I were to discuss it in broad categories, I would say that first, I am one of the senior leaders. I work closely with our director to sort of oversee all aspects of the Institute and everything that we do in terms of how we advance our mission, which is about reducing health disparities, improving minority health, and the promotion of health equity. So that's just really broad. I also work on developing scientific initiatives that fall within our scope, and NIMHD funds research focused on this topic, or these topics, and they're disease agnostic. So we also have partnerships, and we are mandated congressionally to work across all of the NIH institutes to coordinate activities around health disparities and minority health. And then, of course, across the Department of Health and Human Services more generally, I also supervise and oversee the directors of several of our offices, like our Office of Communication, our Policy and Evaluation Office. I also work on just general issues around the climate within our institutes. So I have a set of of areas and tasks that I focus on with what's happening in our institute. So that's separate from the science that we are promoting. And then I work on NIH-wide initiatives, NIH-wide efforts. So I serve as an ambassador, and leading several committees and task forces within NIH more broadly.

Schuyler Lawson  3:59 
I have a follow up question to that. Since the 2020 social justice movements after the murder of George Floyd, has there been any kind of increased interest in health disparities or more funding for health disparities based research?

Dr. Monica Webb-Hooper  4:17 
I'd say yes, I think that 2020 - I call it the collision of 2020, the collision of events that led to an increased emphasis on the reality around structural racism, discrimination, how it affects health, COVID-19, social justice issues, such as police brutality, and you know, we saw many organizations, including NIH, writing a letter or making a statement standing in solidarity, etc. And I think one of the questions that many of us who've been focused on this, not just in the past two years, but for many years, or live it every day, wondered was, how long is this going to remain a part of the conversation? Is this going to stay a significant issue, or is it going to fall apart? I think that what I've observed, and I'm interested in if you see this differently, is that the momentum around this topic and the focus on it has remained. And it's two plus years later in terms of into the pandemic, and we're still concerned about it. I do think that this Institute does receive elevated attention, because this is what we focus on. And so they turn to our institute to look at how do you advance science in this area? With the most recent president's budget, the budget for the country, NIMHD did receive its largest increase since its inception, or becoming an institute, which is with the passage of the Affordable Care Act. And so we did have an increase in our budget, which is pretty sizable, and just allows us to invest more resources into the best science that addresses the areas of greatest interest to us.

Schuyler Lawson  5:51 
From my perspective, I noticed a similar trend, I would say yes. Recent conferences I attended at the Society for Research on Nicotine and Tobacco, there was a heightened focus on tobacco-related health disparities, more than what I was seeing in previous conferences. So I think that there's still the momentum there.

Dr. Monica Webb-Hooper  6:09 
I think so.

Schuyler Lawson  6:10 
So I do have another question for you. What are your specific research interests?

Dr. Monica Webb-Hooper  6:16 
So I am interested broadly, in clinical health psychology, biobehavioral research, health behavior change, all the work I've done, has had the backdrop, for the majority of the work, I would say, the backdrop of Minority Health and Health Disparities within the areas that I'm interested in. I'm also interested in cancer prevention and control, a lot of focus on tobacco use, and smoking and smoking cessation, weight management, obesity reduction. So cancer risk behavior in general, but the types of behaviors that I'm interested in, health behaviors, have implications not only for cancer, but you know, heart disease, and stroke. And so it's really kind of transdiagnostic in a sense, of things that I'm interested in. And I think I've always been interested also, in broadly this category of, that you also hear a lot about now, which is social determinants of health, and how the social determinants of health impact our health in a number of ways.

Schuyler Lawson  7:18 
So for our listeners, could you define what the social determinants of health are?

Dr. Monica Webb-Hooper  7:22 
Sure. Social determinants of health is a term that you see if you look at the Healthy People 2010, 2020, now 2030 effort, and it's really about the conditions in which people live, where you're born, where you work, where you play, where you experience life, and how those conditions have a direct impact on health. So a few examples of those could be the neighborhood that you live in, the access to transportation, the access to healthy food, the access to not only health care, but high quality health care, access to not only education, but school systems with quality education - those are social determinants of health. And it is that these are different from health disparities. And sometimes I hear people kind of use these words almost interchangeably. Health disparities is about differences rooted in disadvantage. Social determinants, they're often discussed in a negative way. So likening them to, and they can be drivers of health disparities, but not necessarily, they also can be drivers of really good health, if you live in neighborhoods and communities where you have plenty of green space, and people are out jogging and walking their dog and with low crime, and everybody has nice cars and great school systems. So those are also social determinants of health, but they lead in a different direction.

Schuyler Lawson  8:42 
Okay. Thank you for that definition. So, getting back to it, you mentioned your research interest in tobacco. So in your view, what drives tobacco-related health disparities experienced by African Americans, because from what I understand African Americans, they bear the disproportionate disease burden when it comes to tobacco-related illnesses.

Dr. Monica Webb-Hooper  9:04 
That's true. And a large part of my work focused on tobacco related disparities, specifically among African American adults. And I think it remains a critical problem to address, I have to say, we need more scientists who are focused on this community because African American people certainly suffer the great undue burden of tobacco-related illnesses. And actually, when you look at it - if you just look at the prevalence of any tobacco use, the prevalence of smoking by race/ethnicity in the United States, you don't see that there is a disparity when you compare white and African American adults, and actually, there was a disparity there. And in the early 2000s, 2000-2001, we saw an elimination of that disparity. That doesn't, however, account for the greater prevalence of smoking menthol brands, among African American adults, which is, 80-90%. I mean, many times at least 90% of my participants were menthol brand - their preference was for menthol brands, compared to about 30% of white adults. But I think the most persistent disparity, if you compare African American males and females to their white male and female counterparts, it's the difference in cessation, that ability to quit successfully over the long term. And we see that in national epidemiologic surveys, we see it in clinical trials. And the difficulty quitting is partly what leads to health disparities. If you can't quit, then you have more years of exposure to smoking, even with a lower number of cigarettes smoked per day, you have the longer exposure because you haven't been able to quit. But I have to also just say that the difficulty quitting that many African American adults experience is not due to just our individual failures, why can't you just quit? It's much more complex than that. There are multiple levels of factors that contribute to why it is so hard for African American people to quit smoking. But certainly, this has to be a priority if we want to save lives and reduce disparities.

Schuyler Lawson  11:14 
I love that you mentioned that it emphasizes not individual failing, and it's actually kind of ties in nicely to publication you had in 2019, when you examined the reasons for exclusion from smoking cessation trials. From my understanding those studies are ways that people can actually get access to free smoking cessation treatments like nicotine replacement therapy or prescription medications like Chantix or Wellbutrin. So could you summarize the findings of that study? And initially, do you think that the findings factor into tobacco-related health disparities in African Americans?

Dr. Monica Webb-Hooper  11:54 
Sure, I think that study, the reason that we conducted that analysis is it was part of a randomized controlled trial, where we were wanting to kind of look at in the larger study, whether or not a cognitive behavioral therapy intervention could eliminate cessation disparities by race and ethnicity. And so we wanted to recruit an equal number, for the most part, of white adults, African American or Black adults, and Hispanic or Latino adults. And so it provided an opportunity to look at, well, we're recruiting these numbers, but are we excluding people based on race, ethnicity, and what would be the reasons for that? There is an act that was passed in 1993. It's called the NIH Revitalization Act. And in that act, it specified that grant proposals are required to include people who are identified or identify as racial ethnic minority persons as participants. And then you also have to describe your planned distribution of enrollment by race/ethnicity, at the end of your grant, you have to report how well you did. So in this study, we weren't able to recruit the numbers that we were looking for. But what we found, when we looked at our screening data, we found that about a third of the sample, a little bit more than a third of the sample, were deemed ineligible. And we had a long list of criteria. This was a group based face-to-face study. So this happened, the study actually ended just before the pandemic. So this was people coming in for face-to-face intervention. So we looked at all the reasons why people weren't eligible. The most frequent reason was serious mental illness. Second was alcohol dependence or drug use, and then barriers to attendance, like they couldn't come in person, would be an example. And what we found overall, was that the ineligibility or being excluded from the study was actually greatest among African American adults, and then second, about 42%. And then Hispanic individuals, 37%, white individuals were excluded at about 24%. So we were significantly more likely to exclude people who expressed interest in the study, but didn't meet the criteria that happened to be African American or Latino. And then we looked at the reasons why. And we found that the white individuals who expressed interest were more likely to be excluded for just one reason, like maybe they had an attendance barrier, or they had a medical condition that would preclude them from using nicotine replacement therapy. When you looked at African American adults, however, this group was more than twice as likely as our white individuals who expressed interest, to be excluded for three or more reasons. So people were being excluded for lots of reasons. And what it highlighted to me, among other things was that it's necessary for some trials to set exclusion criteria because of the study, you have to have inclusion/exclusion criteria, but I think the point is that those criteria may have unintended consequences where certain groups of interested potential participants are being excluded by design. And that might be one reason that this act, the NIH Revitalization Act, still, we have progress to be made in this space. So I think it potentially has implications for health disparities, because, as you mentioned, it's an opportunity for people to have access to state of the art, cutting edge medication, or treatment of whatever kind it is. I also think that when it comes to implementation, and we saw this with COVID in the vaccine trials, it's a bit different. But people are interested in knowing whether there were people like me in the study. And so it also, I think, has implications for implementation and uptake, if we can make that statement that the findings seem to generalize across populations. And I think that's important for reducing disparities and just assuring equity,

Schuyler Lawson  15:53 
Thank you for your answer. So now we're gonna talk about another publication that you had in 2021. And this was a study that tested a Video Text tobacco cessation prevention intervention among economically disadvantaged African American adults. Could you summarize the findings of that and explain their public health applications?

Dr. Monica Webb-Hooper  16:16 
Sure, this was a foray by our research group into mobile health interventions. And so we developed a video text tobacco cessation intervention. And so it was sending individuals, instead of just texts about quitting smoking, or education about why you should, or motivational messages, we actually had developed a video that's called Pathways to Freedom, Leading the Way to a Smoke Free Community. And we used that video, and we segmented it into smaller sections that would send out messages via the videos, parts of the video. So it was video text. And so we compared that in a pilot randomized trial. We call our intervention "Path to Quit", and we compared it to "Smoke Free Text", which is the standard text messaging program that NCI uses, and Path to Quit was based on Pathways to Freedom, so it's culturally specific to address the unique concerns of African American individuals such as the menthol smoking, the smoking of little cigars - things that you don't talk about, or you wouldn't receive in a text message from NCI's Smoke Free texts. And essentially, in this randomized trial, where people received one of these two interventions, plus nicotine replacement therapy, what we found was that at the end of the intervention - it was a first study, so it was a pilot - we looked at people right at the end of the intervention, which was six weeks later, and we found a pretty high proportion of the sample was biochemically confirmed as abstinence at the end of the intervention, which was 38%. And then we did find, and we didn't really expect to see this, that carbon monoxide confirmed abstinence was significantly greater for people who received the Path to Quit Video Text intervention, compared with NCI Smoke Free texts. As a matter of fact, the rate of quitting was 3.5 times greater in the Path to Quit condition compared with Smoke Free Text. And I think for me, when we talk about technology-based interventions, digital health, telemedicine, telehealth, it's really just imperative that all populations have access, can benefit equitably, know how to use the technology. Otherwise, you risk widening disparities, as technology-based interventions become the way of the future. So I think that some of the public health implications are that not only technology might be a way to disseminate interventions across the population, which is really important for increasing reach. But the culturally specific version was better in this case. And in addition to that, something we didn't really expect, but we found when we looked at our data, so in an ex post facto kind of way, that we did have some feasibility challenges. So again, I'm always interested in from an equity lens - who didn't have the opportunity to benefit from this intervention? That's what health equity is about, making sure everyone can benefit. So I'm interested in well, who didn't? And what we found was that, of the people who were ineligible, mostly they were ineligible because they did not have the phones that would be necessary to allow them to draw from the internet. 98% of the participants who were excluded, had Android phones and 80% had no contract Pay As You Go phones from the small carriers. Then of the ineligible respondents about 39% just didn't have the stable Internet access to get onto the internet, which you needed to be able to pull those videos. So I think this study, it shows that you can develop and disseminate a high - an acceptable, scalable tobacco cessation intervention that addresses key community concerns and needs, but you have to be careful about the ability for people to engage and not be left behind as you move toward technology.

Schuyler Lawson  20:03 
I was going to ask about the digital divide, and whether or not there were any kind of differences in effectiveness as a function of age, for example.

Dr. Monica Webb-Hooper  20:10 
So, we didn't analyze the differences stratified by age, but we did find just initially, that age was different when we randomize participants. So we sort of just controlled for age and age did not emerge in our regression analyses as a significant predictor of outcomes. But we didn't actually compare, in a stratified way, to look at whether age made a difference in this sample. But looking in the overall regression, it didn't emerge as an overall predictor of abstinence with either of these interventions. And both, of course, are technology based.

Schuyler Lawson  20:44 
So this is very novel and promising really, because it's a nice improvement with what you described in the 2019 paper about African Americans being systematically screened out in some ways by the kind of existing status quo smoking cessation trial criteria. But what it seems like with studies like this that are more tailored, you can have sort of a broader reach and kind of be able to provide more help, in that kind of scalable and customizable way with technology. You just have to be careful not to exclude people, which is always going to be a challenge.

Dr. Monica Webb-Hooper  21:19 
Exactly.

Schuyler Lawson  21:21 
Okay. This one's pretty pressing, because it's recent news. So what are your thoughts about the Food and Drug Administration's recent rule proposals prohibiting menthol cigarettes and flavored cigars? And also, could you give context to our listeners about why menthol in cigarettes and flavors in cigars are significant tobacco control issues?

Dr. Monica Webb-Hooper  21:46 
Sure. Based on my experience, conducting research and with treating individuals who prefer methylated tobacco products, this rule, if it becomes official, has the potential for strong, positive impact on reducing tobacco use among African American adolescents and adults. Among women and adolescents in general, menthol was the only flavor still allowed in tobacco products in the Family Smoking Prevention and Tobacco Control Act that was passed in June of 2009 by President Barack Obama. And what was troubling for many about that act, although it was a huge step forward in tobacco control,  because it banned flavorings and allowed the FDA to regulate tobacco products for the first time ever, that menthol was still allowed. It was the only flavor that remained there, and that are still allowed in these products. There have been many - tobacco control leaders, advocates, scientists, and community organizations have really been pushing for this, for many years, for this ban. And I think there's empirical evidence that a significant number of people who smoke menthol brands would quit if menthol was not in the product, or at least that's what they report. And if that did happen, it would have a major effect on the health of individuals who smoke menthol tobacco products, it would prevent illness, and it would save lives. And isn't that what we all want?

Schuyler Lawson  23:18 
And what about removing the flavors from from cigars?

Dr. Monica Webb-Hooper  23:23 
I think, again, is that that is important because we know that especially among adolescents, many African American adolescents in particular, not smoking cigarettes, not even menthol cigarettes - they're smoking things like black and mild, little cigars, flavored cigars. And so this could be important for prevention among young people, if you don't have flavors that make it more attractive. I mean, I think it's the same reason why other flavors from other products were removed and why you can't buy candy cigarettes, like we used to puff on when when I was a kid, and you could have these little gum packages that looks exactly like cigarettes - the same reason and that's why it's important not to flavor cigars, and mostly our youth, African American youth, are those who smoke little cigars, and they're flavored, you know?

Schuyler Lawson  24:10 
They're flavored. And from what I understand, they're relatively inexpensive, and they're taxed differently than cigarettes, right?

Dr. Monica Webb-Hooper  24:16 
That's right, and you can buy them in smaller packages. They're definitely not the same as buying an $8 pack of cigarettes. So, I think the point of these kinds of policy changes are about how do we move public health forward? Some people have argued that this is punitive, because they're concerned about the criminalization potential for this, if in fact, it is difficult for people to quit smoking and they are concerned about some sort of menthol cigarette or flavored cigar black market come about, but I think most people are on board with this and want to see it become successful, which would be more likely a huge win for tobacco control and for addressing minority health.

Schuyler Lawson  25:05 
Thanks for that background about public health significance of removing menthol from cigarettes and cigars. So I remember earlier in this interview, you mentioned that African Americans disproportionately use menthol cigarettes. Do you know why that is?

Dr. Monica Webb-Hooper  25:22
Well, I think the main reason is because of targeted tobacco product marketing. When you just - if you're observant at all, and you drive through a neighborhood that has predominantly black or African American residents, particularly a lower income neighborhood with predominantly black residents, and you drive past corner stores, gas stations, billboards, you still see advertisements for menthol cigarette brands. I mean, you see outside the corner stores, you see advertisement for three things: menthol cigarettes, alcohol, and the lottery. And so these kinds of targeted messages have been in the black community for decades, and if you look at the tobacco industry document, and one of my good colleagues, Dr. Valerie Yerger, has written a lot about this and really looked at those documents. And you see the way the tobacco industry referred to, spoke about, and thought of, in African American individuals. So this has been very intentional on their part. And part of the thing about menthol cigarettes, and this is what many of my participants and patients would say is that they taste much better, it's minty, it's smooth, that goes down more easily. So you create a product that allows people to become addicted much quicker, it only takes about three cigarettes to become addicted and you make it taste better and go down more smoothly, you can hook more people quickly. And that's been a major concern with how the targeted marketing has been so successful.

Schuyler Lawson 26:54
So given that menthol cigarettes and flavored cigars have been on the market for decades, what do you think inspired the Food and Drug Administration's proposal to prohibit them?

Dr. Monica Webb-Hooper  27:04 
Well, I'm not an FDA employee, so I can only speculate like everyone else. I would like to think that this proposed rule finally occurred with the mounting evidence pointing in the same direction of menthol cigarettes being harder to quit. And as we talked about earlier, with this emphasis on equity that we've observed since 2020, maybe that had something to do with it. And I think, you know, assuring equity is about doing what is just and fair. And that's been the emphasis about equity since 2020, is correcting social injustices. And so it gives everyone that optimal opportunity to literally live their best lives. And I hope that that is partly what this, that people have advocated for a long time, seems to be possible.

Schuyler Lawson  27:09
I have another question. So if it were up to you, if it was within your power, what type of tobacco control measures would you implement to address these tobacco-related health disparities?

Dr. Monica Webb-Hooper  28:05
One of the most effective interventions or tobacco control measures that you can implement is around policy. Policy change has demonstrated positive effects on promoting smoking cessation, and encouraging people to smoke fewer cigarettes per day, things like increased taxes, making it more expensive to smoke. We also are seeing positive effects from tobacco 21 laws that are now passed in an increasing number of locations - cities, counties - and those prohibit people under 21 years of age to purchase tobacco products. And because of the policies, in terms of thinking about why and how they're effective, because of these kinds of policies, that's why we're not able to smoke in restaurants in most states, some states still don't have full Clean Indoor Air Acts. But we're not allowed to smoke on airplanes and in many public places, so that exposure gets reduced, especially exposure among young people who don't smoke and also children. So I think policies that have equity in the lens from the beginning would be important in any intervention that you're working on, including policy. Who's likely to be punished by this policy, who's likely to benefit? Is anyone likely to be left out? So I would want to look at policies, go back and look at current policies, and develop new policies that would only promote health and not leave someone behind. I think other important measures are in the space of prevention. How do we prevent people from starting to smoke in the first place? I mean, you know the saying, "an ounce of prevention is worth a pound of cure". It's a true statement. It's very true. So should we go back and rethink? Should smoking prevention be part of the curriculum and health courses as early as elementary school, middle school? Should hard hitting campaigns like the Truth Campaign that showed some success be brought back in full force? And then of course, where I've focused my efforts are really around comprehensive tobacco cessation programs that need to be widely available at no cost or low cost, and in communities with high need high smoking prevalence that also include medication, and that are culturally appropriate or culturally specific, because it's certainly one size does not fit all. And we need to think about all of these things given the strength of this addiction, which is really unlike any other addiction.

Schuyler Lawson  30:26 
Very detailed answer. Is there anything else you'd like to share with listeners about your research or about tobacco-related health disparities?

Dr. Monica Webb-Hooper  30:40 
I'd like to say one other thing, or a couple of things about this topic of disparities. It's that health disparities, by definition, are modifiable, and they don't have to exist. The reason that we study health disparities, and we need to continue to do that is because there have been so many significant scientific treatment advances, and they have just not benefited all populations. So it's beyond time that we really hit the gas and move into the third and fourth generation of health disparities science and research where we really are looking at interventions that have the potential or population level implementation uptake outcomes, applying that health equity lens from the start of the process. And tobacco related health disparities, like other disparities are not based on one's genetics, genomics, or biology. It's not about an inherent deficit. These disparities happen, not by accident, because when you look across populations that experience health disparities, they are disadvantaged, and that's the link between all of them, so it's rooted in disadvantage, versus being rooted in differences due to biological or genetic factors.

Schuyler Lawson  31:55 
It is a very important distinction to make. Thank you for making that clarification. Again, thank you so much for taking the time to be interviewed for the podcast. We hope to have you on again to discuss future issues, and also future publications, I'm pretty sure that's gonna happen. And is there a way that listeners can learn more about your research?

Dr. Monica Webb-Hooper  32:17 
Sure. So I certainly encourage everyone to follow NIMHD. We have a listserv that everyone can join by going to the NIH listserv website, and you can sign up and find out all the things that we're doing that have to do with health disparities in general, and also the things that we support that are in the Tobacco Control Space. My own research can, of course, just be tracked through, you know, PubMed and other things. If I publish a new article, sometimes we push it out through NIMHD, depending on what it is, and then I'm also on Twitter. Let's see if I remember my Twitter handle. It's @DrMWHooper. So certainly invite anyone to follow what I'm talking about there, which isn't a whole lot, but mostly the work that we're doing

Schuyler Lawson  33:06 
Will do. I'm pretty sure quite a few of our listeners are on Twitter, so it'll be great. It's good to see scientists promoting their research and their focus on Twitter. That's a good dissemination tool, I think.

Dr. Monica Webb-Hooper  33:17 
Yeah, I agree.

Schuyler Lawson  33:18 
All right, so I'm Schuyler Lawson. Thank you for listening to another episode of Buffalo HealthCast. Take care and be well.

Outro  33:25 
This has been another episode of Buffalo HealthCast. Tune in next time to hear more about health equity in Buffalo, the US, and around the globe.

Intro 0:00 
Hello, and welcome to Buffalo HealthCast, a podcast by students, faculty and staff of the University at Buffalo's School of Public Health and Health Professions. We are your cohosts, Tia Palermo, Jessica Kruger, and Schuyler Lawson, and in this podcast, we cover topics related to health equity here in Buffalo, around the US, and globally. In this first semester of the podcast, we're taking a deeper look at racism and health. We'll be talking to experts around the US, as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population health and wellbeing. You'll hear from practitioners, researchers, students, and faculty from other universities, who have made positive changes to improve health equity and inclusion.

Jessica Kruger 0:47 
I'm Dr. Jessica Kruger, and our guest today is Dr. Sue Mann Dolce. Dr. Mann Dolce's PhD is in Rehabilitation Science, and a clinical background in occupational therapy. She is a Certified International Yoga Therapist, and we're happy to have her on the show today.

Sue Mann Dolce 1:07 
Thanks, Jess, thanks so much for inviting me to be part of this.

Jessica Kruger 1:10  
As we get started, we're going to start with an exercise that Sue would like to have everyone participate in.

Sue Mann Dolce 1:19 
So, if you're listening to the podcast, wherever you are, unless you're driving, or operating machinery of some kind that you can't stop, I'm going to invite you to join me in a centering. So, it's a very simple practice. And you can do it in any position, sitting, lying down, standing, so you choose. And the very first step is choosing the position that you're going to be in. And the next step is to take a moment to notice your body and feel where it's supported. So, for example, if you're standing, feel your feet against the floor. If you're seated, feel your feet on the floor, wherever they are, feel your legs and your hips and your back. And no matter where you are - and if you're lying down, obviously, you're going to be feeling a lot of contact. So, feel what you feel. And then just slowly allow your arms to relax, your shoulders, your neck, and your jaw. And come into the space, noticing the sensations in your body, not trying to change them or judge them, just noticing. And then once you've done that, notice the breath, your inhale as it comes, and then your exhale as it leaves. Again, no judgment - we're not trying to change it. Just becoming aware. And if you're able to breathe in through your nose into your belly, and then release from the belly and out through your nose, you can choose that. But if for any reason that doesn't work for you, that's fine. Breathe in the way that does work for you. And then three full breaths this way. No hurry, taking your time. If you get distracted, that's fine. Just notice it and make a choice to come back, to being present in your body in your breath, to the degree you can. One more full inhale and exhale in your own time. Beautiful, thank you.

Jessica Kruger 3:47 
Thank you for that. Today we're going to talk a little bit about disability and learn about the definitions. So, Sue, could you provide us with a definition of disability and the different interpretations it might take in different settings?

Sue Mann Dolce 4:05  
Sure. And I also want to start out by saying there's many definitions of disability, and different groups are going to talk about this in varying ways. And I'm always going to defer to the group that is speaking, because they may have a unique experience and interpretation. And that's pretty much an overall approach when we're talking about disability, because disability means and is experienced in a number of different ways for different people. But I'm going to go back to the definition under the Americans with Disabilities Act, which was originally passed in 1990, and then the Amendments Act that was passed in 2012. And the definition, the simplest part of that definition, is that disability, or a person is considered to have a disability, if they have an impairment that limits them in a major life activity. So, you have to have both an impairment, and then be limited significantly - limited is the language - in a major life activity. And you can go to ADA.gov, and look this definition up, and there's also some other information there about that. So, I am really interested in this concept of impairment, Jess, because that languaging denotes something wrong, something less-than, something different, certainly. And difference is okay, I like the idea of difference, or I would agree that most of us can appreciate that there's a difference, but not the kind of value laden idea of impairment. So, we often think of it as variance, that you have a variability around something. So, the way you see, the way you hear, the way you feel emotionally, and/or physically, the way you think or process information, the way you move, the way you move certain parts of yourself or other parts. But it also can denote chronic health conditions, whether they're chronic intermittent health conditions, or other health conditions that are pretty chronic all the time, that limit your ability to participate in a major life activity as designed. This gets to a tricky part, I'm not sure if you want me to jump right into this. But a lot of the issues that come up is because of how we design programs, activities, spaces, technologies, and virtual environments. So that's the definition that we work from, in our office. I work in the Accessibility Resources Office at the University at Buffalo. So that's the definition that we're working from. But I also work with a lot of community groups and other groups that are interested in exploring these ideas and concepts.

Jessica Kruger 7:20  
I think you brought up a really important point about language and how we discuss disability. I love the idea of the variance and changing that language right there. Instead of saying an impairment, I think that just has a totally different feel than what we're used to talking about. So, speaking of language, how does language influence our ability to provide individuals with disabilities equitable access to services and support environments?

Sue Mann Dolce 7:54 
Well, that's such a great question, and that, in of itself is a very long time, it might be a course. But anyway, where I immediately go to that is, the way we use language is really an expression of how we think about an issue, a person, etc. And then those influence how we behave in those situations. So, for example, and probably the most prominent example within public health is, do we think that a disabled individual, an individual that describes themselves and identifies as a disabled individual, has insight and knowledge about how they experience the world? Or do we think, as a public health professional, that we know better? So, if we are thinking about this individual as impaired in some way, and we're the trained professional, we don't tend to have a lot of professional humility, and really listen to how people talk about themselves and their experiences. And because of that, our programs and our spaces, all spaces, aren't necessarily designed so those individuals feel welcome in the space and valued in the space. So that's important. Another thing that comes up a lot is, should we say, "people with disabilities," or "disabled people"? We use person choice language. So, if the individual identifies and strongly identifies as "I'm a disabled person," I'm going to use that language with them. In many professional programs, we're trained, or we're training people, or educating people to say, "people with disabilities," with the idea of you do the person first, and then the disability, as if just there's something bad about being disabled, as opposed to a lot of people that are choosing to use - a lot of disability advocates choose to lead with disability. Not that they think that the disability is located in them. But they're saying, "I'm disabled, by the way things are designed, I'm a disabled individual." They see it as a statement of advocacy, calling out the culture per se, that they are disabled, even though they're human, just like the rest of us, have something to offer, just like the rest of us, can contribute to the day-to-day life of the community, the university, etc. Not to mention offer as much in the way of innovation as and excellence as any other individual that's perceived in any other identity group. So how we're thinking and talking about these things, I really think a lot of it goes back to people being able to express what they need, and be heard, and/or seen, whatever that means, whether it's through hearing or through text, etc., or being seen, being described, etc. So we'll see this all the time, and so getting used to your feelings about these things, noticing your language about these things, is a really important first step in getting curious about situations and starting to think about how you're choosing to use language in different situations, and not from the place of having to know, but having the ability to ask, in a way that doesn't put the other person on the spot. "How do you prefer to be referred to", it's kind of like, I would say, "I'm Sue, and my pronouns are she/her." So, it creates a space for someone that may not use the same pronouns to know that I appreciate that. So, we're creating spaces. And there's these ways that we can do that, that are really important for all of us.

Jessica Kruger 12:41 
I love the way that you're talking about creating that space and creating that opportunity. Because in public health, we really want to be centered on the individual, working to make people feel welcomed, supported in any sort of program or activity that we're doing. And bringing up that humility aspect, we talk a lot about cultural humility, but not so much humility in this aspect.

Sue Mann Dolce 13:10  
Well, yes, but disability is a culture. There's a huge disability culture and we need a Disability Cultural Center at the University of Buffalo. We have the IDC, the Intercultural Diversity Center, which is amazing, they do amazing work, but they're not resourced to do disability culture, and there's plenty to celebrate in disability culture. And there's a lot of art, there's a lot of innovation, there's a lot of technologies, there's just so many things to celebrate. So that's a thing to think about when we're thinking about cultural humility. Why aren't we including disability within that, right? So, because disability goes across all other identity groups, no matter what race, ethnicity, orientation, etc., there are going to be disabled individuals in that group, whether it's visible or invisible. So, I think that's an important thing. Then the other component, I had an experience with a friend/colleague, where they needed a ride to get vaccinated, because the vaccination site wasn't near public transportation, that they could easily get to the site. So, this individual doesn't drive, they have a physical disability. They also don't use a power chair or a wheelchair of any kind, or even a mobility device. But they do get around a little bit differently than what we would think of as temporarily abled people. So, I said, "Sure, I'll take you." So dropped them off at the site. Okay, there's a curb, a significant curb. There are steps going down into the site, there's no handrail. And then one of the public health workers comes out and starts talking to my colleague, who by the way, has a PhD in disability, in American history and disability studies, and starts talking to him like he's an insect. "Oh, honey, let me help you," and being somewhat, I would argue, patronizing - it would be like the most generous term I could think of. And I'm cringing, because, you know what we felt like going into get these vaccines. It was not comfortable anyway. Could you imagine that, on top of it, so physically unsafe for him, and then being treated that way? So, what is that individual thinking? That's my question, because I know they didn't intend to be, in any way, inappropriate. Their intention was to be helpful and welcoming. I know it wasn't perceived that way. And then the design of the site; why is it not right on public transportation? Why is there an entry that's not fully accessible? Why would an individual who moves differently need someone who clearly can get around without support if it's designed appropriately? So those are the kinds of, it's so simple, once you see it, right? So, the whole point here is to get people to start thinking about these things and seeing it. So, when you're in a position where you can make a design choice, that you're doing an informed choice. And when you you're not able to do a design choice, and let's say you do need to have someone welcoming people, that they treat people with some respect and dignity. So those would be my main points about these things. So, it all goes back to attitudes, awareness, which circles me back around to this term. Ableism. Do you mind if I talk about ableism?

Jessica Kruger 17:29 
I'd be happy for you to talk about ableism. But first, you used a term that some of our listeners might not be aware of: temporarily abled. Could you explain that?

Sue Mann Dolce 17:39 
Yeah, temporarily abled. I would suggest that most of us will experience being disabled at some point in our lives, whether it's temporarily, we have an injury, or a surgery, or a health condition that's resolved, so we experience that. So that can be a temporary kind of disability, or as we grow and experience the world, we may have some things develop that are more chronic, and then we become limited. So, a lot of times, I think, probably 15 years ago, we would be at meetings, things people would say, "Oh, they're just a TAB." So Temporarily Able-Bodied, right? But, within the disability advocacy communities, and there's many, they focus on individual disabilities, and then overall disability. There's an awareness that these things are fluid, there's a movement to them. And I think most of us and our listeners have experienced that. Whether it's you or someone you love and care about. Once someone has experienced these things, you tend to be more aware of them and appreciate them in a different way.

Jessica Kruger 18:58 
That's so true. I personally, was injured recently and had to go get a handicap parking permit. And in the city of Buffalo, that's a real challenge when you are on crutches, because it's in an older building. And that older building, there are stairs. It's at the lower level.

Sue Mann Dolce 19:16 
In City Hall, right?

Jessica Kruger 19:18 
It is in City Hall.

Sue Mann Dolce 19:18 
Down that long corridor...

Jessica Kruger 19:20 
Long corridor and very back corner of the basement and that tells you something.

Sue Mann Dolce 19:28 
Tells you a lot.

Jessica Kruger 19:32 
So circling back to ableism, can you describe that and its prevalence in today's society and where we see it?

Sue Mann Dolce 19:40 
Yes. I first heard this term at UB when Leslie Freid, who's an amazing disability advocate and among other things, an excellent mutton dancer, yoga teacher, etc. She was here doing some scholarly talks and other work and she did a talk about ableism. And ableism is essentially thinking that everyone does things the way you do. So, you're ableist in the way you design things. So, you're designing for able-bodied people, typically-abled or able-bodied people. And when I say able-bodied, I don't just mean physical, I mean sensorially, psychologically, motorically, all the different aspects of living, and of course, multiple aspects of that wants to for a lot of people. And so how are we ableist? So, it's like a lot of the other isms. It's just actually like that. So, for those of us who experience the world as designed, in general, what does that mean? We turn on our computer, we can access it through a mouse, we can see it, we can navigate the screen by seeing, we can choose to leave and get up and go get something to drink, we can leave the building and go up and down stairs, we can see the controls on the elevator - we just expect all those things. However, if you move differently, see differently, hear differently, that's not your experience of the world. But that's still how the world is designed. And the world is designed that way, because most of the people designing the world are typically abled. So, they're being ableist in their design, as opposed to using universal design or inclusive design, which is very interesting. We have a whole of the Inclusive Design Environmental Access, here at UB over in the School of Architecture and Planning, which is amazing. Go to their website, beautiful, amazing work. We have a whole center that's been funded for years, is known internationally, but we still don't design things for access. We're much, much better than we've ever been. But it takes time. But the single most important thing, and this goes across every research study that I've read, and I've read quite a few, is it's the attitudes towards people, disabled people that have the biggest impact. Design is essential. But of course, the attitudes feed the design. So, attitudes always come first. It's like when we were talking today, I said, I think we need to start with attitudes, because it is the biggest barrier. And so, doing the work that we can do to explore this on our own, to reflect on how do we think about this? And again, not in a judgmental way, but in a getting curious way. Like if I'm working in the office, and someone comes in, that moves differently or sees differently, do I resist that in some way? Do I go, "Oh man, this is going to be such a drag, or "I don't know how to do this," or "We don't have an exam table for that," or, you know, fill in the blank. In some way, we then project that back onto the individual, and they don't feel welcome. Even though the design issue is on our end, you know, maybe not us personally, we didn't design the office, but we work in that space. So, working with our colleagues to say, "Hey, I noticed this today, are there some things that we could do to address this?" Often, there's not a lot of real material things we can do. But we can shift practices, we can shift how we're approaching it, how we're thinking about it, we can schedule differently. So, we can take more time in a way that doesn't make the provider feel rushed, and then that gets projected onto the individual, like there's something wrong with them, because it takes them twice as long to walk to the room. That it takes them, you know, fill in the blank. So, these are all amazing opportunities, but it starts with us reflecting on, when we get that feeling of going underneath it and thinking about okay, why am I feeling this way? Why am I apprehensive to work with this individual? What kind of support do I need, or does our space need to create change around this? And no, it will take time. You don't have to do it in a minute. But getting curious, this is always where we're going to create the most change over time.

Jessica Kruger 24:40 
Really challenging biases and pre-existing thoughts. Speaking of that, we see so much media every single day. And in that media, it seems to influence part of that ableism that we're talking about. Could you speak to that?

Sue Mann Dolce 24:58 
I could, but there's someone who could speak a lot better to this, who is Beth Haller, H-A-L-L-E-R. And she has a book called "Disability in the Media." Excellent, highly recommend it. She also has a few blogs and different things that she does about disability in the media. Beth was here, did a public talk here at UB on South Campus, pre-COVID. She's quite an activist. So, in terms of disability in the media, the short answer to this is pay attention to media. There's two primary tropes or ideas that we'll see in the in the media, about disability. It's disability and in disabled individuals, and the charity model. "Oh, these poor people, we need to take care of them." And then the other is the "Super Crip." Look at this amazing individual, disabled individual, and what they accomplished. They're amazing, right? So, what we don't see often is just day to day people, living their lives, just like everybody else. Disabled people are part of our community every day, all day. And we're not necessarily seeing those people represented in the news. So, thinking about, what is that about? Part of it is over half the people with disabilities have invisible disabilities. So, you may be seeing people in the news and hearing about people in the news who are disabled, but they're choosing to not disclose that, which is fine. But a lot of the reason that they don't disclose it is because of ableism and negative attitudes and the stigma of being perceived that way. So, I have a personal experience of this. So, pay attention to what happens when I tell this story, for yourself as you're listening. So, I went undergrad for OT at the University of Buffalo. I love OT and I love the University of Buffalo. When I was an undergrad, I had a fairly significant mental health issue. And this was a long time ago, we didn't have the same supports that we have now. And I didn't have a lot of support in my personal life related to this for a variety of reasons. And so, it was very, very difficult for me for a while, but I figured it out. It's actually when I found yoga. So, I've been doing yoga and meditation for years because it was a huge help. But I also found support through professional providers and medication, etc. So, I was very lucky that I had access to these things, and so figured that out. And for years, I never disclosed that; that I have a mental health disability because I have a history of it. So, the fear of disclosing and being overlooked in for promotion, hiring, etc., is very real. And I can see when I'm talking to individuals if I choose to share that. And often people will say things to me, like, "Oh, I'm so surprised." And I'm not, you know, sometimes "I'll say what does that mean?" And they say, "Well, you don't act like you would have a mental health issue." And bingo, it's like, what does that mean? What did people with a mental health issue act like? Someone has an idea of that. The person has an idea of who that is. Right there. That's the underlying issue related to ableism, attitudes, stigma, etc. So, getting underneath...now, I disclose all the time if it's relevant. But how did you feel, listening to that? Knowing I have a PhD, knowing I work in this area, I mean, unless you've heard me say this before, disclose before. So how we think about people, the assumptions that we make, are merely that. They're assumptions. And we all know what assumptions get us, right? So going underneath, thinking about it, and until more people can really claim their full identity, because we've created a culture where that's okay, where you're not going to be retaliated against in some way. So, these are really important concepts to think about and to explore. And again, I can't emphasize enough, the people that I was just referencing who would ask those questions, I totally understand. It's not like I'm judging them, I understand where they're coming from. But them having that moment and noticing it, and my gently calling attention to it, hopefully, is the beginning of them exploring to create change, because if we're all doing this, we will continue to create change. Some of us have the luxury of having an invisible disability, but many, many people don't. And they don't get to choose, they're treated, they have to be ready at any moment to be treated disrespectfully or not be included or not feel welcome in a physical sense, or in an environmental, attitudinal sense.

Jessica Kruger 30:58 
So it sounds like there's a lot that all of us can do, getting curious, challenging our biases, thinking about how we're feeling as we're interacting with any individual because we don't know if someone has a disability.

Sue Mann Dolce 31:14 
Right, exactly. And asking, but not asking so that the disabled individual has to do all the work. The burden is not on the disabled person. And we need to be cognizant of that, too. So, this is the other big thing that comes up a lot, is the over ask, you know, can I help you with that? Can I do that? Can I do this? I did it Saturday, I was with a friend at a market, and they had a couple bags, I had a couple of bags, but we encountered some stairs we didn't know we're going to be there, because there was no signage telling us. And I immediately just turned around and said, oh, let me take your bag. And they were like, I got this. So, I was like, Okay, great. So, you know, back off, and I could really hear them and appreciate that, right? So, the over ask - implying that someone's not able. That person hadn't asked me, they weren't struggling in any way, there was no overt need. But I stepped in immediately. I have to own that. And acknowledge it, "Sorry about that." "No problem." So, it's not like these big things. It's these ongoing little things. And I make mistakes every single day. Like I just expect to make mistakes, I don't love it. But I do it. And then I repair it, without it being a burden on the other person, meaning not calling them out on it, not making a big deal about it. None of those kinds of things. And we hear these same concepts in other conversations about other people who do things differently than we do, for whatever reason related to identity.

Jessica Kruger 33:05 
Well, it all comes back to humility. Really thinking about how you can learn and grow as an individual, and be okay to make mistakes, because we all do. We're human, right?

Sue Mann Dolce 33:18 
I agree. And then as professionals what we uniquely can offer, but not having that professional identity override the humility, right? So, the number one thing about health care disparities, disabled people tell them, one thing they say is, "Listen to us." Right? Listen to our experience of this. But you hear the same thing about the maternal health of black women, like the white version, not listening to our experience, not listening to what we're telling them, etc. So, we hear this, it's the same thing we hear over and over and over again, for people who systems are not necessarily designed for, quote, unquote.

Jessica Kruger 34:00 
Speaking of that, thank you so much for being part of this podcast and for all of our listeners for listening, learning, challenging, and getting curious. Any last words?

Sue Mann Dolce 34:12 
Just thank you so much. And thank you to all of you who did the beginning centering practice with me. I appreciate that too. I could feel you out there.

Jessica Kruger 34:23 
Thanks so much.

Outro 34:32 
This has been another episode of Buffalo HealthCast. Tune in next time to hear more about health equity in Buffalo, the US, and around the globe.

Introduction: Hello and welcome to Buffalo HealthCast: a podcast by students, faculty, and staff of the University at Buffalo’s School of Public Health and Health Professions. We are your cohosts, Tia Palermo, Jessica Kruger, and Schuyler Lawson. In this podcast, we cover topics related to health equity here in Buffalo, around the U.S., and globally. In this first semester of the podcast, we’re taking a deeper look at racism and health. We’ll be talking to experts around the U.S., as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population health and wellbeing. You’ll hear from practitioners, researchers, students, and faculty from other universities who have made positive changes to improve health equity and inclusion.  

Kellen Montanye: Landon is a 21-year-old Life and Transition Coach who owns his own company, LKM Coaching. He uses social media as an influencer to educate others on topics of transitioning, hormones, and surgeries to the public. Landon is a resident of New York and is also here today to speak on the medical issues that transgender people face within the health care system. Okay, our first question is: What are some of the health issues or barriers to seeking care that transgender individuals face?

Landon McNee: As a trans man myself, I feel like the biggest issue has been finding educated health care staff that is willing to treat my gender dysphoria. Ultimately, it comes down to the fact that there’s such scarce knowledge, and there’s not really as much culturally competent care for everyone that most medical professionals preach. It’s just more of a new topic that’s still being discussed and rehearsed within the medical field.  

Kellen Montanye: No, that’s great, I completely agree. Do you think that this comes down to the training that medical care professionals receive in their schooling, or do you think that it’s the lack of keeping up with that medical education training later on, after being in the profession, in their jobs and their careers?

Landon McNee: I think it’s a combination of both. If you think of it within the last decade, there’s been so much progress that’s been made within the trans community. Even within the last few years, if you said “trans,” some people didn’t even know what that meant. Now, you say “trans,” and everyone knows what the means. I think that this is an overall new topic that’s being discussed in society, whereas before, it was way more taboo, just even a few years ago. Going back to training and bringing in people within the communities (the trans community, the LGBTQ community, etc.), it’s an area that’s still being discovered. Having people such as a professional, like me, as part of the trans community, can be a huge asset to medical professionals. For example, I was working with my local hospital in order to create culturally competent care for all. It was an LGBT resource team that I worked as a community committee member for. I think those things can be huge towards making really big transitional pivots in the medical field. I am happy that there are big changes that are being made. Even 7 years ago, for instance, when I first started hormone-replacement therapy, I had to give a urine sample. This was a gender clinic in New York City, and I had to give a urine sample, and they didn’t have a gender-neutral bathroom. I was not male-passing at the time, and I had a near-panic attack trying to figure out which bathroom I was going to go to, and this was an appointment towards my transition. Those little things, and creating awareness about those things, and creating spaces, is huge, and the first step towards making progress. I feel like I’m going all over the place, but ultimately, those all connect.

Kellen Montanye: That’s a great point – I totally agree. I think it’s great that you had the opportunity to be part of the committee to create culturally competent care for people who do identify within the LGBTQ+ community, specifically trans, because that is something that is very lacking in our society. So, our second question is: When you came out as trans, how did that impact your ability to seek medical care and treatment, initially? 

Landon McNee: I’m going to be 22 in a few weeks – I came out at 14, so it’s been about 7 years. Coming out at a really young age, especially when transitions were not really talked about at all, a lot of health care providers were in question of whether or not to take my transition seriously. Luckily, my parents were able to commute an hour and a half to New York City – luckily, I live that close to one of the greatest cities in the world – where there’s a lot more progression and a lot more resources. They took me to a trans adolescence health care center in New York City, through Mount Sinai Adolescent Health Center. They did think that they were taking me to a conversion therapist because their ignorance was so strong – their acceptance was there, but their understanding wasn’t. They thought I was too young to make any sort of changes – that this is something that just needs to be talked about and ultimately, I will grow out of it. When it came to going to college, I went way up north in New York. Things changed a bit. All psychiatrists and therapists seemed to focus on my trans identity as my cause of depression and anxiety when in reality, that was already being treated for the last few years. Between the ages of 14 to 17; 14 and 15, I was very much so told “You’re very young – you need to talk about this in-depth before any permanent changes are made.” Then, I was diagnosed with gender dysphoria within my therapist’s credentials. They were like, “It would be best, at the age of 16, you could start hormone-replacement therapy”, so I did. And then I graduated high school at 17. When I went to college, way far up north, where health care is totally different than it is in New York City, they just kept focusing on the fact that my identity was the cause for my mental health being in shambles. I would say, once again, a lack of knowledge-pushed me to educate my doctors and look for another health care provider willing to listen to all of my needs, rather than just focusing on an area that is more taboo and seeking more interest.

Kellen Montanye: Wow, that’s a great explanation. To see the differences between the quality of health care within a city population and more of a rural area in Upstate New York just goes to show how different the medical care is on the receiving end and also how that lack of education and communication within the medical community is not equal across the board. So, that’s a great thing to share, thank you. Our next question comes to, how do you believe that the medical field is failing the transgender community?

Landon McNee: The thing is, I want to reflect this back to whoever may be listening to this. I’m speaking on behalf of my own experience, so every other trans person in the community has their own opinion. For me, I think overall education and willingness to listen to their clients is the overall issue. At the same time, I know that a lot of other trans people feel that you shouldn’t have to advocate for yourself. I completely agree, you shouldn’t have to. At the same time, if nothing is being said and no one is speaking up, no progression is going to be made. There needs to be this light that doctors are still human beings that need to be just as open-minded as any other person, and you grow as an individual. That is just a part of any profession, any human being – you grow, and you learn. It’s just a part of the contract you sign when you are a part of society – constantly learning. Just because a doctor is viewed as the elite in care doesn’t mean that they are versed on how to best support each client. I think, opening their ears and listening to what their patient needs can be very huge because I can very much attest to the fact that there are doctors who will simply just not treat me because they are not comfortable treating trans clients (patients). If I walk in, and I’ve been on testosterone for 7 years, there is no reason why a doctor cannot do simple bloodwork and prescribe me my testosterone right off the bat. Just being overall more open-minded to working with a diverse population can open a lot of doors.

Kellen Montanye: Yeah, that’s also a great point. I think, especially, because some people, like myself, have to travel multiple hours away just to get the quality care that, not only we need, but what we deserve. I think that pointing that out, that every person’s journey within their transition, is different, and so are the different things we have to do in order to get that quality of care. I think that’s a really great point because there are multiple ways that the medical field is failing the transgender community, it’s not really just one. I think that’s a great point that you make. Our next question is, when it comes to insurance approval for medical transitions, what barriers did you, or do you currently face?

Landon McNee: One thing that really came up in regards to insurance – when I first started my medical transition, clearly, all my insurance paperwork had my birth name, and my sex assigned at birth. Whenever testosterone was being filled, I would have to deal with a pharmacist. So, I would get this long list, the first time I was prescribed testosterone, I got this really long list from the pharmacist. He was an older man, probably in his early 50s, and he’s working alongside a younger woman pharmacist. He kept asking all these questions and he said, “Is this girl pregnant?” He didn’t notice that I was the person that was going to be taking this testosterone. He thought that it was for somebody else, and he was trying to say, “Is she pregnant? You need to make sure!”, and the woman standing next to him was like, “No, no, no.”, being aware that this is clearly something different, this is being used for transition purposes, and there was a lack of knowledge there. That was pretty unfortunate and pretty uncomfortable, sitting there, and they are reconfirming all of the things that you wish you didn’t have and the reasons why you’re transitioning is to feel more comfortable, and to stray away from that female identity, and my female-assigned sex at birth. Fortunately, my testosterone has been covered through insurance – I've never had an issue with that. My top surgery was not. That was considered cosmetic and paid for out-of-pocket. At the same time, I needed a mental health professional to sign off on my gender dysphoria in order to follow through with the procedure ethically. It seemed very, very contradictory, and to this day, I still have an issue finding a provider that is well-versed in hormone-replacement therapy in my area. It’s left me to self-educate and work with my primary health care providers. To this day, I just work with my primary. I get my bloodwork taken every 3 months, and then we go from there. I don’t even work with a specialist. My insurance hasn’t really had an issue. I will add that for surgery, the surgeon I picked was a well-renowned surgeon, and having surgery almost 5 years ago, I think insurance has come a long way. As far as I know, a lot of trans guys’ top surgeries are being covered nowadays. But during that time, it was not covered for me.  

Kellen Montanye: I completely agree how the insurance is making that revolution, very slow, but it is making that revolution towards catering to transition procedures for trans folks. For myself, luckily, I did get my top surgery covered. I was very thankful for that. I did have some barriers with my testosterone, and being able to get it, but I do think that you’re 100% right, that it is slowly coming through to have a little more light addressed, and being able to, not universally be covered through every insurance, but it is coming through to be able to be a little more accessible for people who may not have that resource right away. It’s a great point that you make there as well. Our next question is, the Electronic Medical Records (EMR), are very binary when it comes to documenting patient health information. In addition to a section for a preferred name, gender identity, and pronouns, what other information could be collected to prevent discrimination and barriers within transgender patients.

Landon McNee:  I actually have a tiny story that happened a year before COVID. I was at work and I cut off a little piece of my fingertip. I had to get an X-ray, and going from person to person, like you would in the ER, everyone is looking at your medical records. Each person you go to, they ask the same questions. There was one guy when I went to go get an X-ray for my finger, and he looked at my documentation and goes, “Hm, it says that you’re female in here, it looks like it’s a mistake, I think we got to change that.” I’m just sitting there, laughing a little bit, and I didn’t even bother to explain. Whatever, if he wants to change it to male, change it to male. Now, looking back at that, there should be some sort of documentation because, the thing is, I haven’t had bottom surgery. In regards to whatever complications that may come up in the ER, I feel like there would be an issue with insurance wanting to cover a hysterectomy if my sex says that I’m male on paperwork. Having information that says I identify as male, but also, I was female-assigned at birth, can avoid a lot of those issues. I think there is no real, proper education for trans people in the system, and there should be a quick summary about how the person identifies and some overall general info on what it means to be trans. Say that, a speaker comes in one day, and the X-ray technician was not there that day. Missed the whole big education aspect to treating trans people. Well, there should be some sort of backbone or backup. There should be some sort of summary underneath to help treat trans people. It should also be allowed for the patient to choose whether or not the provider can see past medical records that show their sex assigned at birth, due to safety issues in today’s society. That is really unfortunate. I do feel that, working in the medical field, that it should be separate – your opinions versus treating someone with respect. I think those are very huge. Keep your opinions outside of the workplace. When it comes to treating everybody equally, there is a right way to respect someone and that also has to be with trans people. It goes back and forth - medical professionals should have the right to see all medical records, at the same time, I understand the safety issues with that as well. I’m sure with time and further education...If there is a more instilled overall medical – I don’t even understand how I would word this – but, school laws in New York State: all schools have to follow such-and-such for discrimination, right? The same thing should have to do with the medical field. I’m not sure if that goes as far as that, but I think that would make a big difference if that even makes sense?

Kellen Montanye: No, I actually do understand that. When I used to work at a hospital, locally here in Buffalo, we did have to do LGBTQ compliance, but it didn’t ever go into how you would continue to give care to somebody related to their gender identity, or specific types of medical needs that may come with sexual orientation – different things like that. I think it’s covering part of what somebody needs to learn, but it’s definitely not thorough and it’s not delivered in an applicable way that you could say, “Oh wow, from this training, I could probably do this here for this individual, who identifies as trans.” It’s there, but it’s definitely not where it needs to be – it's much subpar. I completely agree. This leads into our last question here, which covers: What other trainings or interventions for health care providers can additionally help prevent discrimination and barriers for transgender patients? This does go a little past my explanation right there, with potentially making the LGBTQ competency training, that is annual, a little more in-depth or applicable. Just wondering what you think any other trainings could do, as per preventing discrimination for trans people?  

Landon McNee: I think, as you said in my bio, I have made it my specific career path to educate those around LGBTQ issues and equality. I think it’s super important to reach out to specialists in this field. What better resource than to go to the community themselves, and for people who have made it their mission to make massive change? Continuing education and regulations need to be put in place in all health care systems to overall best provide for all communities, not even the trans community, but for all diverse communities. I think that’s very, very huge.  

Kellen Montanye: Continuing education and regulations – that's a great topic to go on, and I know I could probably go on all day about that. Landon, I want to thank you for coming today. I think that this is a very educational and forward message to anybody listening to this about the transgender community and how the medical field is not where it needs to be for trans folks, and their health, and their transitions. I just want to thank you for coming today.

Landon McNee: Yeah, of course! Thank you for having me, Kellen. I think that having this conversation in general is going to open up a lot of discussions, and ultimately, that discussion will lead to some positive change.

Outro: This has been another episode of Buffalo HealthCast. Tune in next time to hear more about health equity in Buffalo, the US, and around the globe.

Intro   
Hello, and welcome to Buffalo HealthCast - a podcast by students, faculty, and staff of the University at Buffalo's School of Public Health and Health Professions. We are your co-hosts: Tia Palermo, Jessica Kruger, Skyler Lawson, and in this podcast, we cover topics related to health equity here in Buffalo, around the US, and globally. In this first semester of the podcast, we're taking a deeper look at racism and health. We'll be talking to experts around the US, as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population health and wellbeing. You'll hear from practitioners, researchers, students, and faculty from other universities who have made positive changes to improve health equity and inclusion.

Jessica Kruger  
Today's guest is Cindy McEachon, who is the CEO of Peaceprints, a local organization helping individuals who are justice-involved and recently released from a justice setting. She holds a degree in Health and Human Services from the University of Buffalo. Welcome, Cindy.

Cindi McEachon   
Great to be here.

Jessica Kruger  
Could you tell me a little bit more about Peaceprints and what they do for folks in the Western New York area?

Cindi McEachon  
Sure, Peaceprints is a reentry organization that has been around since 1985. We have all sorts of facets of programming, working with all sorts of individuals from all walks of life. The common thread is that there is justice involvement on some level. So, we work with every jurisdiction level: local, state and federal. We have housing programs, we have intensive case management models, so more community-based, we work with young people, families, and we have our food pantry. So we do a lot with folks both inside the facilities as well as out in the community.

Jessica Kruger  
That's excellent. It's so great to hear that folks are working with individuals in all sorts of settings. Now, can you tell me a little bit more about the background of scale of incarceration in the United States?

Cindi McEachon  
Yeah, we are certainly number one in this space. We have over 2.3 million individuals that are incarcerated on some level. So, whether that is local, state or federal, and another four and a half million that are out under community supervision actively, so we definitely incarcerate at the highest value. We are, putting it another perspective, only 5% of the world's population, but we incarcerate 25% of those incarcerated, here in the United States. So incarceration, mass incarceration, mass supervision is a way of life here.

Jessica Kruger   
Wow, it's amazing to think about not only people who are physically within a facility, but under supervision in some way, shape, or form. That's a lot of individuals, and I'm guessing this affects the communities. Can you tell us a little bit more what you see?

Cindi McEachon   
Yeah. So, you know, you figure 2.3 million people are currently behind bars, but 95% of those individuals are coming back into our community. So, they make up what is now that number of four and a half million that are currently under supervision, but that's not counting the individuals who have satisfied that supervision, who are no longer under or may have gone to jail but are back out and did not have supervision. So, we have this plethora of people that aren't even accounted for in this mix as well, but the key here is that 95% of the individuals who are incarcerated will come out likely under supervision back into their community. And that in and of itself, causes huge ripple effect because you've extracted somebody for an extended period of time, and then placed them back into the community where they have to assimilate. On top of that, there's a ton of research to show that there is an increased or an elevated rate of chronic disease, of substance abuse, of mental illness, of health-related concerns when an individual is incarcerated. And a lot of that has to do or is fueled by environment. And then we're going to release individuals, right?  95% - that's our number - back out into the community when we've already increased some risk. So it's a very overwhelming system.

Jessica Kruger  
I'm so glad you brought up the challenges with chronic diseases among folks and as they're released back into communities. Can you tell me a little bit more about some of those health challenges in which people are facing after they've been released?

Cindi McEachon   
Yeah, I mean, when you're talking about chronic illness, we've had individuals that have had pretty intense surgeries. So, we're talking heart conditions, we're talking about things like that, that health ailments that have helped, or happened while they were incarcerated, because they're also older in age, right?  We have an aging prison population right now. So, we're not talking about as many young people, not that that really makes a difference, as it still impacts your health overall. But we have seen how the effects of mass incarceration for decades. And what we have is an aging incarcerated population, who's now going to come out into the community. So, they're already older in age, you have naturally occurring diseases and illnesses that we see in the community often happen, a little bit later in life, happening earlier, because they're incarcerated. So, you will have diabetes. You will have, unfortunately, we've seen a lot of folks with cancer coming out more recently. You have individuals that have had kidney failure, or the amount of medications individuals tend to pass through our doors, carrying with them, and then that's not counting where they stand in terms of the mental illness, right? If there is trauma that's been experienced, they're battling depression, or they do have a serious mental illness documented, and there's medications and/or treatment required in alignment with that. So, we have folks that kind of run the gamut when it comes to what the need might be. What we find to be most overwhelming is that when an individual returns, they don't have a history, per se, of having a family doctor, or their health history documented, that is available to agencies in the community once they're released. That information stays in prison, and so it stays in the facilities and doesn't come out with them. That's very overwhelming; we find that they have a very limited supply of their medications made available to them. Sometimes individuals don't even have active Medicaid when they come out. And so, if that's not already activated, pre-release, we're starting behind, right from the onset of release. And that's only if we're lucky enough to have an individual pass through our doors and we become aware. We certainly do not work with everybody that returns from incarceration that comes back to our community. And when we talk about these huge numbers of releases, we have, unfortunately, a lot of individuals who fall in the cracks who are not necessarily connected with services or don't have somebody to try and connect them with appropriate resources.

Jessica Kruger   
Wow. So, when we say incarceration as a public health problem, this is really hitting on so many levels. Not only while individuals are being incarcerated, not only communities but also this can impact their health as people are released, not knowing their medical records coming out, possibly sicker than when they came in. And so, this is something that we really need to talk about within the public health community more than we do now. What would you like to see if you had a magic wand and could change the system after someone was released? What do you think would be the ideal way to help people kind of go back into their communities?

Cindi McEachon   
I would say with my magic wand, we would have increased accountability and communication. Those two things, I think, would shift one's access, and what it looks like to connect with resources from inside to outside.  Unfortunately, what we find is that communication is stunted at release. Sometimes it's nonexistent or incredibly limited at what's made available or what the person is bringing with them. You also have such unique stories person to person. So, if an individual was incarcerated when they were 18 years old, and is now being released at age 55, their entire adult life has very little record outside of what happened in the facilities. That's a really difficult space to start and to be able to connect somebody with resources. But then on the outside, that's really where I think accountability is huge, is that we do have a multitude of providers, of helping spaces. Another area where we struggle is that there is zero accountability on the side of providers. So, when you talk about social determinants of health, you talk about access to services, you talk about this as a public health crisis; accountability plays a role because service providers also realize that there's little happening prior, so there's little expected after. And with that mentality, sadly, being at the forefront of what fuels a lot of this, individuals and their families are set up to fail every step of the way, and then are blamed for it. But in fact, we've made it incredibly difficult for them to access what they need. It's very frustrating. So, I would say communication and accountability on both sides, you know, certainly necessary. And I think that would improve things a lot.

Jessica Kruger  
I can't imagine spending the majority of your adult life in a criminal justice setting, and then being released, and not knowing how to navigate the system, possibly even how to advocate for yourself. And going through that with a chronic condition could be incredibly challenging for individuals. So, tell me a little bit more. When an individual’s typically released, do they typically have Medicaid? Are they connected with a primary care doctor? What is that communication, or maybe that communication gap between release and during release?

Cindi McEachon   
In a perfect world, yes, they have Medicaid already activated pre-release. We know our world is not perfect. Sadly, it's kind of a toss, right? We really don't know upon arrival, if somebody is one of the lucky few that did have their Medicaid activated prior to release, or if they fall into the group that did not. I will say, we see more and more that fall into the "did not get connected", unfortunately. I think there's multitude of reasons. For a while, the state was pushing, on a larger scale, connecting individuals prior to release. I was seeing change. As an agency, we were noticing that at release, more folks were coming out with their Medicaid activated. However, policy changes, COVID, all sorts of shifts to the way we were doing business, has changed a lot of the way things were operating. And so now individuals are getting out faster - individuals who didn't think they were getting out and had more time, all of a sudden, don't, and are eligible for release because of law changes and policy changes that have happened, and sweeping reform that has come in without prior planning to ensure that they don't fall through the cracks, because there's not an ability, on the system side, to catch up or prepare for that in advance. Sometimes it's happening in incredibly short notice, and so we have seen over the last 18 to 24 months, sweeping changes in New York State and its impact on pre-release planning, and what that looks like upon. So, already, not great, has become incredibly difficult. And when you break it down, I truly do believe, and I spent a lot of time going inside state facilities prior to COVID, you have some awesome people that do work in these facilities that are working towards the greater good. But facilities by design are in rural communities, are not typically connected to spaces where the majority of individuals are going back, and it is difficult on the side of the staffing, even, to have updated information, be able to access service and advocate for an individual prior to release, even in the old system. Because it just wasn't created to make it easy. I think COVID took that and dropped it on its head, on a whole different way, because all these agencies, whether we did great business or poor business, all of us were impacted by COVID. Many agencies shut their doors, changed the way they were doing things, shut down particular services or programs, and there's no way for information to transfer to the 50-plus facilities across New York State. And that's not even counting the jails - that's state facilities, right? And so, this is a big deal. When you're talking about pre-release planning, when you're talking about access to information and connecting an individual for post release service, it's become even more difficult.

Jessica Kruger   
Yeah, I know many of us really want reform in the criminal justice system and really want to change the way things are being done, but you're right. We're not thinking about some of those other ripple effects that this has, especially on the individuals who are being released and not having that planning and that opportunity to get things in line or even communicate to organizations in which they may be going to, or working with.

Cindi McEachon   
Right, when the primary method of communication is a typed or handwritten letter, and I mean, typed from like a typewriter, or handwritten letter. It's a needle in a haystack - you throw it out there and just hope, whomever you sent that letter to, to offer or ask, is still around. And not only are they still around, that they open your letter, and then from opening it, that they actually respond to you. These are all things, that, in our world today, in our society, we don't really do that. We want instant, even as providers, so we want to be able to email, we want to be able to pick up the phone, worst-case scenario, and call. But sadly, you got to take the time to handwrite or type a letter response back. And that's how information is passed. And that's pretty difficult, right? When you're prepping for a release.

Jessica Kruger  
Wow, it's like time traveling to a different world. So, these are a lot of really heavy topics that I don't think a lot of folks think about on a daily basis. So when you think about what your organization does, and the impact that you have on individuals, could you tell us a little bit about some success stories that you've had and what your organization is working towards in the future?

Cindi McEachon  
Absolutely. You know, I've been doing this for about 11 years now, and sometimes, just getting connected with services will be success, right? Or it could be, you have a complicated story, and it's taken three staff and a phone call for me, and constant letter writing and bothering people to get you a birth certificate. And sometimes it's that, right, and we have to celebrate even the tiniest of wins. But on a large scale, when we find folks satisfy the terms of their supervision, take it to that next level - they've got a job, they've rekindled relationships with their loved ones, they're driving, they own their own vehicle, some of them have their own places, whether that's an actual house that they've purchased, to opening their own businesses, right? It depends on the person because it's so highly individualized. But when you hear, each step of the way, these little successes that compound into something larger, because they beat the odds. I think that for us is what fuels us to keep going. I mean, we're all human. There's not one of us that doesn't wake up some days and just not want to do something, feel unmotivated, or make, maybe, not the greatest decision. We all do it. That's the beauty of it. That's actually life, that is not being a good or bad person, that is not being incarcerated or not. That's truly life - we all experience this, and the individuals we work with are living just like we are. And so, we look for all of these little wins. And in some cases, these larger ones, of where does this take us? Where does this go? We had one individual pass through most recently. He actually was highlighted in our annual appeal this year, but Eddie is his name, and Eddie has gone through our Bissonnette House transitional program. So fresh out of the facility, graduated, moved into our Hope House program. He's off parole, he's working, he owns two vehicles at this point. He is thriving. And he's so excited. He's even advocating for people to make donations to us, right? I mean, this is just mind-blowing, right? When you think of these wins, and for us, it's these stories, right? Another young lady that, I don't know, from when I met her five years ago, to now she's working two jobs. She's in her own apartment. I mean, she's doing great. And she's off supervision, right? These are the things that, and we remain in contact, we have conversation. She has her ups and downs, life still happens. But these are the stories, and I firmly believe it's access to that opportunity. And unfortunately, this particular industry in the space often denies access, truly denies access to individuals and then blames them for not persevering or trying to push past what we denied. And when you just offer that little bit, that opens up access, and people just move with it. And it's pretty amazing to see.

Jessica Kruger  
Thank you for sharing those stories. I mean, I'm sure you have hundreds and hundreds more of the successes that you find with all the individuals that you work with, and your staff works with. It's been really interesting to learn more and more about incarceration in the US and see some of the disparities with things that you have talked about, whether, who's been incarcerated, but also the access. Could you speak to that a little bit?

Cindi McEachon 
Yeah, you know, over the years, I think what was one of the most eye-opening for me - and I identify as a white female, I grew up in a suburban town, and I come back, I move into the city, and I start working with individuals and people of color that are justice-involved. And what I started seeing was the inconsistencies of individuals passing through my services, this is all walks of what I've done. So, all the spaces where I've worked in, participated, or volunteered time, and depending on what they look like, what I draw from them in terms of their conviction, or the amount of incarceration they've done, vary greatly, simply by the color of their skin. And this is, before we were, sadly, even recognizing it. It just happened to be something I was noticing - that I could talk to a young man who's in his 20s, who's white, and this was his first time incarcerated, and he only was in for, you know, a year and is now out on parole. Then I look at a young man, same age, who's Black, who, in my opinion, has a lesser conviction, but was incarcerated for a longer period of time, and also got a longer sentence attached to him, which was fascinating to me. I could not wrap my head around how or why it was happening. And I was newer into the industry, you know, at that time, but it was just fascinating to me how no one talked about it. No one recognized that as a concern, or an issue, and truthfully, that the majority of the individuals I served were people of color. That was the majority of the individuals. Why was that? Why is that? I am thankful that we are moving in a direction of acknowledging it now. I think we have a long way to go. But we're at least recognizing that there's some error there. But it's very real, and so it started to come down to communicating with individuals and just pointedly saying, it's not fair. It's not right. But we need to use the fact that I am a white woman, and I'm a CEO, to break barriers. It's not fair and it's not right that I have to use that. But I want you to know, I recognize the privilege that I have with it. And I need you to share with me what's happening, and together, we will go through this until the world shifts enough that we don't have to do this and that your voice is heard. But our choices are get angry, and have no change, nothing happens, or go through this together. And that has been my motto and the way we've gone through things, and I think that's rippled out through the agency, and become ingrained in the culture of the organization. Would love to see full-scale change, and I can give you countless stories of where we've had to use our privilege, where I personally have had to in situations, and it shouldn't be that way.

Jessica Kruger    
Yeah, I think you bring up a great point in the fact that we really need advocacy on this issue from all levels. And, sadly, at this point in time, we do have to use our privilege to speak for others who are not heard as much as others are in this world. And hopefully, I'm right there with you, I can't wait to see change continue. And I think by spreading awareness about what's happening as people are being released, and even the disparities in which are occurring in and out of the criminal justice system, I hope to see that, and I am so glad that there are so many passionate people like you working on this project and many projects like it around the US. So, I thank you so much for your time, and before we go, I would love to know what's next for you and the organization.

Cindi McEachon    
Well, we are looking to keep moving and grooving, challenging the status quo, and hopeful that we will bring about some new housing opportunities, hopefully, sooner rather than later. But that's a difficult thing to maneuver through, in terms of the politics of it, but we're really excited just to grow as an organization. So, we'd like to extend our housing accessibility, and really start paying attention to, I think I'd mentioned earlier on, the aging incarcerated population. Well, if you are older while you're in, you are even older when you get out, and finding suitable housing for individuals that are older in age, and appropriate housing, if you will, that is clean, safe, and affordable for somebody. We are looking to fill a gap that we're seeing or recognizing, trending higher here locally, which I'm assuming is happening nationally. And then our in-prison program, we have a collaboration with the local jail with an innovative program called Project Blue. And our goal is for our program that has served just over 300 individuals over the last couple years, could expand to become a jail-wide program and so, hopeful that that's on the horizon, and we'll continue to move. That program is currently being followed by a team of researchers from Georgia State assigned to us from the federal government, so the Department of Justice and the Bureau of Justice Assistance gave us a grant to actually collect data points on this program and determine if it could be a national best practice model that we could see implemented in other spaces. So kind of cool - happening here in Erie County.

Jessica Kruger    
That's fantastic. I can't wait to see where you go, and the organization goes and helping others. We'll link in our show notes to Project Blue and some other information about the organization. I'm Dr. Jessica Kruger and I was joined by Cindy McEachon today, the CEO of Peaceprints. Thanks so much for tuning in.

Outro  
This has been another episode of Buffalo HealthCast. Tune in next time to hear more about health equity in Buffalo, the US, and around the globe.

Rachel Wenner: Hello, and welcome to Buffalo HealthCast - a podcast by students, faculty, and staff of the University of Buffalo's School of Public Health and Health Professions. I'm your host, Rachel Wenner. In this podcast, we cover topics related to health equity here in Buffalo, around the US, and globally. In the second semester of the podcast, we’re taking a deeper look at health inequities with a broader lens - focusing on a wide range of health topics. We’ll be talking with experts around the US, as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population health and wellbeing. You'll hear from practitioners, researchers, students, and faculty from other universities, who have made positive changes to improve health equity and inclusion. I'd like to note that today's episode focuses on sexual and domestic violence prevention and includes discussion around topics on this matter. The team and HealthCast recognizes that these topics may be difficult for some listeners, and we encourage you to engage with this podcast in a way that is supportive of your needs. Today, our guest is Kate Rogers, a current PhD student in the Department of Community Health and Health Behavior within the School of Public Health and Health Professions here at UB. Kate is also a graduate of the Master of Public Health program, and former Sexual Violence Prevention Coordinator at Crisis Services Erie County, and Erie County in Buffalo. She is currently working with the organization doing a hospital response. Kate, thank you for joining us today.

Kate Rogers: Thanks so much for having me. It’s my first podcast.

Rachel Wenner: Mine as well. To start, do you want to give us a brief overview of some of the work that Crisis Services does to prevent violence, and some of the roles you've played in your time with the organization and at UB?

Kate Rogers: Yeah sure, you did a great primer with your bio. Crisis Services is the area county’s crisis response agency, so we offer a lot of different services. The department that I worked in is called the Advocate Department, and we are responsible for both prevention and response work in the domestic and sexual violence arena. Fun fact: we are Erie County’s only Rape Crisis Center and basically what that means is that we partner with every hospital in Erie County to do response. If someone shows up at the hospital, we will be paged out by a provider to offer advocacy services, help with law enforcement. If someone has questions about that, we offer court advocacy - all the things that go along with reporting or experiencing domestic or sexual abuse. I currently work for crisis services in a per diem capacity, doing just hospital response, because those PhD demands got to be a little too much, but I was the Sexual Violence Prevention Coordinator for quite a while. I actually had a number of different roles in the agency. I started as a case manager, working with domestic violence survivors, and moved into a campus advocate role which sort of straddled domestic and sexual violence advocacy, case management, and prevention work, and we have a really unique prevention program. We would do a lot of bystander trainings, we’d enroll the community and the broader social ecological model of folks, if you will, who can help with response and prevention of sexual violence. And then, once I left the campus advocacy role, I moved into the role of Sexual Violence Prevention Coordinator, managing a grant that worked on sexual violence prevention, primarily in adolescents, so our focus was 8- to 24-year-olds, but really on our project we worked with high school populations in Erie, Niagara, and Monroe counties. Obviously, all of that work has rolled over into my studies. When I was working on the MPH - my first day of the MPH program was also my first day working at crisis services - so it was a lot of new things starting back in 2018. It was just really cool to see in real time, things I was learning from the program play out in my day-to-day life. I can remember looking at the social ecological model in a health behavior class and I'd be like, “Oh, oh wow, this is also in a prevention presentation that I'm learning about,” and all of the factors, and brief crisis advocacy, and domestic violence tends to fall a lot in the social work realm. But I was fortunate - I had supervisors who were public health folks, and we really took a public health holistic approach to this work, particularly in prevention and it just synced up so amazingly with the program and ultimately, it's kind of what drove me to want to get a PhD in it, too.

Rachel Wenner: That's incredible, thank you for sharing. I know that from personal experience just having real world, real time public health experiences, whether it be volunteer or field training, while simultaneously taking classes really helps to connect the dots between what you're learning on paper and what's going to be applicable once you're done with whatever program, so that's awesome that you've been able to get a wide range of experience within your specific academic interest as well. Could you tell us a little bit about the background on teen dating violence prevalence and how it's a problem today in Erie County and Western New York region?

Kate Rogers: How much time do you have Rachel? We could do that all night. Yeah, so basically an overview - teen dating violence is essentially intimate partner violence experienced by adolescents and teenagers. It tends to show up a little bit differently than it does in adults, but essentially, it's a power disparity in relationships. Somebody in a relationship has an upper hand and they’re taking the power away from someone else in the relationship. The way that it manifests in adolescents, a lot of the time, especially younger adolescents, is a lot of emotional, psychological, verbal abuse, interestingly. From a gender perspective, I feel like a lot of us tend to think of intimate partner violence in general as something that men perpetrate and women experience. In adolescents, it can tend to manifest the opposite, so adolescent girls - there's been a lot of studies, where they are meaner to their boyfriends and more emotionally abusive to their boyfriends, but as they get older there tends to be more of the aggressive forms of abuse - physical abuse, sexual abuse, that are perpetrated by men to adolescent women. It's estimated that one in four teens does experience teen dating violence. I would say, take that number with a grain of salt because it's also highly underreported. Adolescents, as a whole, don't really want to talk about this stuff with anybody, but especially they don't want to report to adults. There's a myriad of issues that happen with reporting that can prevent someone from wanting to report, and so we know that these numbers are probably lower reported than what's actually happening. And we've seen that, going back to this as a harp on the social ecological model, we've seen that when there is a lot of rape culture and victim blaming culture in a school - again, the experience I have is doing this in school settings - if the faculty and the teachers and the adults in the school have that very heteronormative, victim blaming, rape culture - a rape myth acceptance vibe, if you will - the students tend to mirror that in a lot of ways. That stuff that happened at the community level tends to trickle down to the relationship and the individual level. A lot of the goals in teen dating violence prevention will get not only talking to the teens themselves, enrolling the entire school- it's an easy space to do it because most adolescents are in school - enroll in the whole school, instead of saying, “This is what we're seeing, these attitudes and rape myth acceptance, victim blaming/victim shaming attitudes are not great.” Some people are not even aware that they're doing it because it's so embedded in our culture, and by working with both the teachers, the faculty and the students sort of simultaneously, the intention is to create a safer environment.

Rachel Wenner: Awesome, so you touched on the different level factors that affect adolescents’ willingness to seek help and support if they're experiencing something along these lines. How does this translate into negative outcomes, either in adolescents, with their health status or their educational attainment, however that translates, later into adulthood?

Kate Rogers: There's so much research about this. If anyone is unfamiliar, I highly recommend just googling the ACE study (Adverse Childhood Experiences). It was a groundbreaking study - I won't go into too much detail about it because I’m sure a lot of listeners are already familiar, but essentially, the crux of it is that we know that if an individual experiences violence in childhood, whether that's community level violence, so if you live in a place that there's a lot of gun violence prevalent, or just other community violence or domestic violence in the home, it internalizes violence as a conflict resolution mechanism, and normalizes it as a way to handle conflict going forward. So, interestingly, a lot of adolescents - we know adolescents are very influenced by their peer group - it's a time when gender norms are being solidified and worldviews are coming together, and there's been some really incredible studies that have shown that peer groups that normalize violence as conflict resolution tend to have more violence happening in them, and often the victims of violence are not actually even aware that what they're experiencing is violence, because it's been so normalized. So, case in point, again, this is very prevalent with adolescents, because of the ubiquitous use of technology in the form of our little computer - pocket computers or phones - I thought that made me sound really old - but there's a lot of coercive sexting that can happen, or pressure to send nudes or to do something that they're uncomfortable with, and a snap of yourself nude or something like that. A lot of times, adolescents don't even recognize that as problematic behavior, because it's just something that all of their friends do, all of their peer group does, and being pressured to do it seems like it's par for the course. This is abuse that's happening because we know that once that happens in the technological space, it's more likely that abuse is going to happen offline as well. Even if it doesn't transfer offline, there's a whole host of issues happening with technological sexting stuff, if you will. But it's so normalized – it’s part of what adolescents do with each other - they don't know that it's not okay to have someone pressure them for that. Sorry, I got a little bit off on a tangent there, but basically, all of this to say that once this behavior is normalized, you're more likely to see this power disparity and see these kinds of coercive tactics as normal in future, adult relationships, and the long-term impacts of abuse…It usually starts off with technological or emotional or psychological abuse, and then moves into physical or sexual. It may not, but usually it starts off with the things that are not noticeable to other people, and then gets more into the sphere of things that may or may not be noticeable. What ends up happening is that, as we move into adulthood, you have all these chronic stressors of gaslighting, all the markers of psychological abuse, where one person is controlling another person and that manifests in really negative health outcomes like depression and anxiety. Depending on the level of violence in the relationship, PTSD can be really big issue. Being victim to abusive relationships in the future, if you normalize that this is what happens in a relationship when you're young, it's probably how they're going to happen in a relationship as you’re older. And those negative health outcomes - all that chronic stress, ultimately can lead to risky sexual behavior, unwanted pregnancies. The risk is pretty high to not preventing or understanding dating violence as a teen.

Rachel Wenner: Thank you, you touched on some of the ways in which this translates into health outcomes. I was just wondering - I know that your specific area of interest has been in young adults and the 8 to 24 range, but have you noticed any disparities during equities relating to the prevalence of violence in different racial or ethnic groups or different socioeconomic statuses among schools?

Kate Rogers: Yes, I feel like anecdotally, a lot of the schools that we've worked with - that we were able to have access to - were mostly affluent middle class, predominantly white student populations. The prevention work that has been done in a lot of these arenas has been done in affluent upper middle class white populations, but all the literature and all the evidence show, that particularly black adolescent girls are some of the most at risk for experiencing intimate partner violence, so there's a huge disparity in the prevention research and what the response on the ground research is telling us. We also know that any gender non-conforming LGBTQ+ folks are at higher risk for experiencing sexual violence in particular. Most of the prevention research has been done on heterosexual students, so there's a disparity in the way the research is being done. I can't say for sure why that is because I haven't done any of the violence prevention research, per se, that has led to these programs like Green Dot and Bringing in the Bystander. All I can say is that everything that I have read has said more research needs to be done in different communities to see how this holds up and I think that - I could get on my soapbox for a second - that's a really important thing for us as researchers to be looking into. It's easier to gain access, sometimes, especially if researchers are working at a college and the college has a good relationship with a local high school, they can just slide into that. There's a number of barriers to researching minors as anyone who's tried to do research in that arena has experienced, but it's not an excuse, and we need to figure out how these prevention programs can both reach and be tailored to populations that are not that heterosexual, white, cisgender population that has been studied so much in all of this.

Rachel Wenner: Absolutely, and you mentioned how there was different barriers that students face, whether it's in the relationships, like their teachers or authority figures, and I know that you had done some work to study how different policing practices or even the youth attitudes in the schools or the school policies that are in place, can help to either promote and facilitate violence within schools or kind of work against it. How might some of these be evident, either within the schools you're working with, or in other programs across the area?

Kate Rogers: The most important thing is, as I was saying earlier, when there is higher level of rape myth acceptance, and to clarify for folks who aren't familiar – rape myth acceptance is a scale that was developed in the late 90s, I think, but don't quote me on that, and it essentially measures how much a community is willing to accept victim blaming. So, it has things on the scale, like “I think if a girl gets drunk, it's her fault that she’s sexually assaulted,” or “if a guy drinks too much, it's not his fault if he rapes someone,” - those kinds of things. And I think that the way that - the research plays out the way that my experience has played out - when those rates are higher of rape myth acceptance in a school or in a community setting, it's more likely that there's going to be some victim blaming that happens, so that's a huge barrier to coming forward. You’re a 16-year-old kid - you're afraid that if you come forward to your teacher and you say, “Hey, my boyfriend has sexually assaulted me - I don't know what to do” and your teacher says, “Well, you were at a party and you were drunk, what did you think was going to happen?” That's an enormous barrier to reporting. You don't want to feel that kind of shame. I think in the larger setting, in general, police response - it can be very officer dependent. You can have an officer who gets it and who has gone through a lot of cultural sensitivity training and who is wonderful. And you can have an officer who may have seen this person report multiple times, multiple rapes, and they're just like, “I don’t believe this person anymore.” So, unfortunately, at the response level – it’s pretty individual. Overall, community to community, it's more individualistic than it is as a whole. I can say, “I'm going to go to this police department and they're going to respond great.” It's very dependent on the officer that you get. I think in terms of making it better, what schools could do specifically - is train their staff, train their faculty. There's something called disclosure training, where someone from a Rape Crisis Center will come in, and they'll basically say, “Here's how to do this in a trauma informed way.” So, I've done some trainings with various security officers at different campuses, and I get it, you know? A law enforcement official or security official’s job is to figure out what happened. My job as an advocate is not to question someone. It’s just to believe them because I'm their advocate. I'm not - my question needs to hold up in a court of law for them - I'm here to be their support network. But if you're a police officer, you need to figure out what's going on, so you can bring a case to the DA’s office. You may have to ask them questions that are going to be a little different than what I'm talking about as an advocate, and so a lot of what that disclosure training looks like is ways that you can make it more trauma informed, more sensitive. So instead of saying, “Oh yeah, you were really drunk. Why'd you take that sixth shot?”, you can say, “You were drinking - do you want to tell me a little bit more about what happened when you were at the bar?” So, it's not an accusing way - it's, “I need to understand what you drank, for whatever purposes,” but I'm not going to ask it in a way that says, “You were drunk, so of course it's happened,” if that makes sense.

Rachel Wenner: Yes, thank you, and the work that you've done on the grant within Crisis Services focuses on the Bringing in the Bystander curriculum, which works to integrate some of these different concepts that you've mentioned into supportive environments. How has this been effective in preventing violence, and do you mind just touching a little bit more on what the program encompasses?

Kate Rogers: Yeah, so, bystander intervention training - there's several different programs. The one that I'm the most familiar with is Bringing in the Bystander. It was developed by Soteria Solutions. There's another one called Green Dot, which is very similar. They both have college campus and high school level and community level bystander training. It originated with college campuses after there were very high rates of sexual violence on campus. And then, once they saw the success of that, it was adapted for adolescents. So, there have been many iterations of many programs that have worked up until this point. I'm personally partial to Bringing in the Bystander because I'm the most familiar with it, but they're all good. It's interesting - the evaluation processes for a lot of them - so my entire cumulative project - is that what they're calling it now for the MPH? It was called something different when I got it, but my whole project was basically evaluating these programs and sort of evaluating their evaluations. By and large, they've done great work showing, while the program was implemented, rates of sexual violence have dropped. Particularly extensive research on college campuses, which is great. There's not really longitudinal data to show what these attitudes look like, once the program has stopped being administered, so the way that Bringing in the Bystander is structured: it's a seven-week program for adolescents. The college one looks different, so we'll focus on the high school one here. It's a seven-session [program], I should say, and it can be administered across seven days - it can be administered across seven weeks. Typically, in my experience, it’s been administered across seven weeks, and then it gives a little bit of time for them to percolate on the information they've been given. There's a pre-test given at the start, and a post-test given at the end - very classic evaluation mechanism. It just assesses what they've learned, it assesses their attitudes, and that's about it. We know in that seven-week time frame, typically generally speaking, attitudes have shifted a little bit from the start. Someone will maybe say they'll agree with something that's a little more victim shaming and by the end they'll say, “No, I understand that that's not the right way to do it anymore,” which is great, but there's a lot of testing bias that happens in that, because at the end of the seventh session, this stuff is really fresh in your brain. You’re probably going to remember it better than if we tested you six months from now. There is a lot of social desirability bias, so people know how they're supposed to answer these questions, for the most part. The data is maybe not as reliable as it could be, and really, we don't know how this information continues into later adolescence and adulthood, because we're not tracking anyone. It would be an enormous undertaking, but it would be a really important thing to learn, to see how this programming sustains long-term violence prevention and there's not really a good answer for that, that I'm aware of right now.

Rachel Wenner: How does the curriculum work within norms in place within a school, whether this be gender norms, injunctive norms - that work to promote a healthier environment, or provide a barrier for one?

Kate Rogers: This is a tricky question, Rachel. There's a lot of different dynamics that play when you're working with the school, and some more conservative school districts don't love it. There have been instances where parents don't want their kids involved. Typically, the school will say, “We want this programming to happen,” and then the Rape Crisis Center will go in, but parents have to be notified that the kid is receiving this. A typical model would be coming into a health class because it's an easy place to slide this topic into. Parents have the right to refuse their kid this education, so they could pull their kid out. You have to notify the parents. If you're in a - not to stereotype - but if you're in a really conservative district, or a space where people aren't comfortable talking about sex, this is a very taboo topic. It can either result in some kids not getting the education, it can result in a lot of really interesting pushback from the students. The administration can sometimes use it as a way to check a box and say, “We did this violence prevention, cool,” and then they don't necessarily want to involve the rest of their staff or faculty There's a lot of different situations when the greater school, as a whole, doesn't want to be involved, it doesn't really work. We're just giving this education to the kids and we're saying, “This is what a healthy relationship looks like,” and “This is what healthy gender norms look like.” It's great for them, except if the whole structure around them is still supporting a more patriarchal, heteronormative view of things, it's not reinforcing what they've learned, and if they're going to feel ostracized, it's just not going to be effective. It works better when everybody wants to get on the same page, and everybody wants to learn. We recognize that these are hard things to talk about, and they are still, in 2021. Talking about sex isn’t normalized, and talking about gender roles and gender disparity isn't normalized the way that it could and should be to really make this task easier. It's a heavy lift.

Rachel Wenner:  When you're working with these schools, who might be experiencing some sort of prevalence of teen violence, and you provide them with this data, whether it be the pre- and post-test results, or some of the findings that you've come across through working with the students themselves. What are some suggestions that you might make to the schools themselves, or the parents or the students within the classes that you're teaching to bring this information that you're bringing to the students, beyond just the seven-week period, or create more of a community or institutional-level changes, you might think?

Kate Rogers: The model is, of course, meant to be really holistic. It's the same concept - you want to go in as the guide, but you're not the one making the decision. Essentially, if I'm coming in and I'm implementing bystander training somewhere, I can say, “Here's the information we collected - what are your thoughts on this?” I can offer my recommendations, but I think working with any community, like any good public health strategy would do, you let the community decide what those findings will dictate, and sometimes schools are ready, and sometimes they're not. Sometimes you'll have a few faculty who are so genuinely excited about it and so jazzed about the work, and you know they're on the ground and they've seen a lot of things, and they really want to be able to support their students There are administrations that, for whatever reason, aren't ready to buy in, and that's okay. It's not something that can be forced, and I think if you don't have the buy-in from the top, it's very, very difficult to get things rolling on the ground. The best practice is that administrators and school boards, and all the decision-making stakeholder powers that be are really bought in and really involved. I've worked on some college campuses where that's happened, and it's been phenomenal. You've got people at the top, who are just firing off stuff and “This is great - we want to have presentations, we want to have better support services, we want to have this, that, and the other,” and it's wonderful. I worked in schools where it hasn't really gone over that great, and it puts a lot of burden on the one or two faculty members who are very excited to do it, and they're always restraining against their administrators. Ultimately, it's the institution's decision whether or not they want to do anything with the information that we've provided, and if they do, we're here, and even if they don't, we're still here. There's a lot of instances where they're not ready for the prevention portion, but you know we're here to back up any kind of response that anybody needs. It’s tricky.

Rachel Wenner: Yes, and that is a perfect example of probably something we both heard multiple times, and the key component, engaging stakeholders, and the complex events that occur between trying to communicate data and guide some sort of action, whether it be implemented or not, but I think that the educational work that you guys are doing is incredible. As a society, whether it's on a college campus, or something we could do to support the students and the adolescents in our local communities…What are some steps that we can take as individuals or groups to try and break down some of these more traditional normative beliefs and facilitate a more supportive environment?

Kate Rogers: I think the best way to do it, and this is one of my favorite things to talk about, is to work from the bottom up. We like to call it the “Pyramid of Violence”, where the base of the pyramid is all the norms that uphold the stuff in a society that makes things like gender based violence okay. The bottom of the pyramid is racist jokes, sexist jokes, homophobic jokes - things that are normalized in our culture as “funny,” (air-quoting ‘funny’ because they're not funny). Calling those behaviors out with our friends is hard to do when we're living in a very politically and emotionally charged time around all of this. For the better part of the last two years, a lot of us have been having really hard conversations with people we love when we have differing views. Whether you're talking about the coronavirus vaccine, or you're talking about sexual violence, it's kind of the same thing, and calling people out when they make jokes or say things that are maybe inappropriate, that are quote unquote “funny”, is the best way to do it. Once we start to normalize that that stuff's not okay, it makes it harder and harder for this up the pyramid. That objectification of people who are different from us, the othering of people who don't look like us, or behave like us or sound like us. It makes it harder for that to be okay. I think that's the best way to do it, really, it sounds cheesy, but truly be kind to each other and look out for each other.

Rachel Wenner: That’s an awesome message, thank you. Is there anything that you'd like to share, about your work, either within the school or professionally, or advice you'd like to give us as we wrap up?

Kate Rogers: Oh boy, I don't know if I'm qualified to give anybody any advice. I think I’ll keep my message the same: just be kind to each other. I feel like that's something someone famous says… I think, at the end of the day, everything that we do, and most of everything that happens in public health, is hard work. We certainly don't do it for the accolades, and we don't do it for the awards, but I think the most important thing is, whether you're working one to one with someone, or with a big community is public health officials and public health folks - we're not the experts in that. The people who live the experience are, and I think the more we listen, and the more we really work to understand the populations that we are working with, the better the outcomes will be, and it might sound cliché, but I really believe that. I guess that would be it - my advice would be to listen and be nice. Thank you.

Rachel Wenner: Well, thank you so much for joining us, and I know that it must be absolutely crazy busy this time of the semester as you're going through your PhD program, so thank you so much for taking the time out of your busy schedule to talk about this important health issue and shed some light on the ways in which it might be affecting our communities in ways that we might not even know.

Kate Rogers: And I really appreciate you all having me on as well, and I would say to offer support. Crisis Services does have a hotline that's 24/7, so if any listeners need anything: 716-834-3131.

Rachel Wenner: Thank you, and we'll be sure to link any additional resources with the episode description as well, in case anyone would like to know more, or is looking to get some support themselves or share it for friend, for that matter. Thank you.

Kate Rogers: Thank you, Rachel.

Rachel Wenner: This has been another episode of Buffalo HealthCast produced by the University at Buffalo. Tune in next time to hear more about health equity in Buffalo, the US, and around the globe.

Dr. Palermo: Hello and welcome to this episode of Buffalo Health Cast. I'm your co-host Tia Palermo and today I'll be discussing inequities in abortion access with my guest, Deborah McDowell Hernandez and Lucinda Finley. Welcome to you both.

Deborah McDowell Hernandez : Thank you for having us.

Dr. Palermo: Debora McDowell-Hernandez is the senior director of public and community affairs at Planned Parenthood of Central and Western New York, where she's worked for the past three and a half years.

Lucinda Finley is the Frank Raichle Professor of Law at the University at Buffalo. Her areas of expertise include reproductive rights and justice, gender and the law, tort law and First Amendment free speech. She is the author of several books and many articles in leading law journals. She has also argued a major case concerning the clash between the right to safely access abortion services and the right to protest before the U.S. Supreme Court. She also has handled numerous cases in the federal courts of appeals.

I'd like to start today with Deborah. Can you tell us a little bit about the geography of abortion access in the United States?

Deborah McDowell Hernandez: All right, certainly. First off, I would just like to say we're in. We're lucky to be or fortunate to be in the state of New York, which has a very abortion friendly legislation or law. We have the Reproductive Health Act, which was passed in 2019, which protects our access and right to abortion. But I don't think a lot of people realize how inaccessible abortion is in many parts of this country.

And although abortion is still legal in the US, if it's not accessible, what's the point of it being legal? And according to the Guttmacher Institute, thirty four percent of women or I can say individuals ages 13 to 44 live in states that are supportive of abortion rights, whereas 58 percent of people ages 13 to 44 are in states that are hostile or extremely hostile to abortion rights.

Dr. Palermo: And when you say supportive or hostile to abortion rights, can you just tell us a little bit what you mean there?

Deborah McDowell Hernandez: Right, so when I say supportive, I mean states that have created legislation to protect access to abortion. They don't require patients to jump through hoops to get an abortion, a state that might be hostile, although abortion is legal in that state. They might have all of these laws requiring a person to get an ultrasound and then return 48 hours, 72 hours later for another appointment and perhaps require that they have biased counseling that isn't medically accurate. But just making them go through these hoops for the sake of shaming them and just making having the actual abortion difficult.

Dr. Palermo: And you mentioned individuals of reproductive age, so realizing the importance of inclusivity and how diverse our community is. What can you say about people who have abortions?

Deborah McDowell Hernandez: Well, we can say that everyone who has an abortion or who is pregnant or has the ability to become pregnant might not necessarily wish to be identified as a woman. There are many people who have children, raise children, or choose not to have children, but they are. They identify as non-binary or gender fluid. So, trying to look at this from the lens of diversity and inclusion and not excluding anyone, I might refer to folks as individuals or persons instead of always women.

Dr. Palermo: Thank you for clarifying that for us. So, Deborah, can you give us a little bit of a background on the types of individuals who get abortions, some of the statistics and characteristics of people getting abortions in the U.S., right?

Deborah McDowell Hernandez: Most of us probably know someone who has had an abortion. One in four people in the US, will have an abortion by the age of forty-five. 59% percent of people who have abortions already have one or more children, so it's not something that is highly unusual. 75% of abortion patients are poor people of all races and ethnicities, and of a variety of faiths make a decision to have an abortion. And as far as race goes, white women make up the highest percentage of abortions at 39%, Blacks at 28% Hispanic or Latino at 25%, and other races account for 9% of abortion patients.

More than half of the abortion patients in this country are in their 20s, and they are in adolescence also make up 12% of patients.

I just I don't want to drown you with statistics. Abortion rate in 2017 was 13.5abortions per 1000 women aged 15 to 44, and that was down eight percent from 14.6 per 1000 in 2014. And 18 percent of pregnancies in 2017 ended in abortion.

Dr. Palermo: Thank you for that very comprehensive overview. Drilling down a little bit, can you tell us a bit about the abortion procedure? So, when during pregnancy, do most individuals seek abortion and how risky is an abortion procedure?

Deborah McDowell Hernandez: Well, first off, abortion is a very safe procedure. It's one of the safest medical procedures. anti-abortion folks or anti-choice folks will have you believe that abortion can cause cancer and all of these other things that just are not true medically and scientifically inaccurate. But very few people have complications or serious health effects as a result of having an abortion.

So, it's a fairly simple medical procedure to have. Two-thirds of abortions occur at eight weeks or earlier, and 88% occur in the first 12 weeks. And again, as I said, there no relation between breast cancer and abortions, even though people will try to create these false narratives. People, if you can, we have there are a couple of options. Surgical abortion is one option. Medical abortion, which would involve ingestion or taking a tablet medication, is also an option for patients.

We recently had someone from the state of Texas who visited one of our health centers and was unable to get the medical abortion. But we called out to another health center in the Buffalo area, and they were able to make space for them to get a surgical abortion.

Dr. Palermo: So, you mentioned that an overwhelming majority, so 88% of abortions occur in the first 12 weeks of pregnancy. What are some reasons women seek abortion after the first 12 weeks?

Deborah McDowell Hernandez: Well, abortion is a very personal decision. So, there are a variety of reasons that people have this as their final decision. And sometimes it's just a matter of, you know, could be for emotional reasons, financial reasons. I've heard people who decided to have an abortion because they would have felt trapped in an abusive relationship. They were being emotionally or physically abused and knew that was one way that this partner would have kept them if they were forced to have a child.

So, some people might make a decision to have an abortion simply for their own mental and emotional well-being. There are times when people might opt to have an abortion because of financial limitations. Maybe they don't feel like they have the financial means to care for themselves or another person could be other things happening in their world. Medical reasons a person might have some health condition that would make it very risky for them to continue with the full-term pregnancy and deliver. Or there could be an issue related to the fetuses’ health. So, I think there's just a variety of reasons. But the biggest thing at Planned Parenthood, we try to always respect that it's a personal decision for the individual or anyone else they want to include in their circle, be it a faith member on family and friends.

It's their decision to make and we want them to have the right to make that decision without feeling shamed or stigmatized or anything like that.

Dr. Palermo: How do people pay for abortions?

Deborah McDowell Hernandez: And again, you're going to have a variety of ways, depending on the person's own financial background. Some people are able to pay completely out of pocket if they have the financial means, they might do so in their home state outside of their home state, even outside of the country. People who don't have the financial means might do so with some government assistance.

There are states that are very hostile and you won't be able to get any support from them, but people are able to access abortion sometimes even with the help of their home state, the help of private funds There are many abortion access funds throughout the country that are funded through the generous support of

Individuals, or organizations who want to make sure that abortion is accessible to those with limited means and those with means in between. So, you have a variety of ways in which people pay.

And then if you have an organization like Planned Parenthood and many other organizations throughout the country, they might honor a sliding scale system and different people might pay different things, be it for it could be some sort of family planning, type of service or STI treatment.

So, it's not necessarily one size fits all. A lot of it, depending on where you are, the state for county in which you live in the health care provider that you are visiting might have some flexibility and understanding what you can't afford.

Dr. Palermo: So, you mentioned state funding in some states for abortion. Can you clarify for us whether federal dollars can be used for abortion coverage?

Deborah McDowell Hernandez: Well, with the Hyde amendment that prohibits the use of federal funds for abortion, but even in New York State, New York State supports costs for abortion if someone needs that. So again, when I say about depends on where you live, the state in which you reside, it could be just, as I said, an abortion supportive state like New York. Or you could be in a hostile state which might not offer you much, except for a lot of hassle.

Dr. Palermo: So, I'd like to turn now to Professor Finley speaking about payment and access and coverage.

What can you tell us about what the Affordable Care Act says about insurance and abortion coverage and how does this vary by state?

Professor Finley: The Affordable Care Act does not require that insurance plans cover abortion, it requires that insurance plans cover maternal maternity care. But not abortion.

Again, some states, including New York, have state laws that require that insurance plans within their state have to offer coverage for abortion, but that that New York law is currently under court challenge by employers who are using religious objections that they don't want to be forced to provide insurance to their employees that covers abortions. So, you know that that's a potential barrier to the law any laws that require private companies to provide insurance coverage to employees that covers abortion.

Dr. Palermo: Can you take us back a little bit, Professor Finley, and talk about maybe give us a quick overview of cases important cases in the U.S. with respect to abortion?

Professor Finley: Sure. I'll concentrate on the two main ones because there are way too many to talk about in this podcast, but you know the case that everyone I think knows by name, but few know what it really said is Roe v. Wade, which was decided by the U.S. Supreme Court in 1973. And in this case, the U.S. Supreme Court held that there was a fundamental right of a woman to choose whether or not to carry her pregnancy to term or to terminate her pregnancy, in other words, to have an abortion.

And the U.S. Supreme Court said that this fundamental right was based in constitutional notions of sort of life and liberty that included a right to privacy and the privacy of one's mother making decisions about one's own body. And that was a 7 to 2 decision of the US Supreme Court. You know, people tend to forget that, you know, once upon a time, the idea of abortion becoming legal was not as controversial in this country as it as it is now.

And then in the early 1990s, the other significant case is one called Casey v. Southeastern Pennsylvania.

Planned Parenthood and Casey involved a challenge to whether numerous types of state restrictions on abortion were constitutional or not. Under Roe, the restrictions involved in Casey included a waiting period where a woman had to first consult with the health care provider, then wait a certain period of time to rethink and then come back. It included a requirement that minors have to get the consent of their parents.

It included a restriction that women who were married and want an abortion had to get the permission of their spouse.

In the Supreme Court, Casey struck down the requirement that a woman has to get the permission of the spouse. But it upheld the other restrictions and it changed Roe in a significant way that made it possible for state laws going forward to become more restrictive or hostile, as Deborah said. So, Casey said that although women had a fundamental right to choose whether or not to have an abortion, the state, the state, the government also had its own right to protect potential life. And in balancing those two rights, the court said the state could put limits on abortion that were intended to protect health.

Such as you might regulate any medical procedure, but it also said it could put limits on abortion. As long as they didn't pose an undue burden on a woman's right and they defined an undue burden as a law that either had the purpose or the effect of putting a substantial obstacle in the way of women, and the court went on to say just because you make it more expensive. Just because you make it take, we have to wait longer, just because you make women have to travel further. Those aren't substantial obstacles.

So, Casey really unleashed decades of state laws in the hostile states where they said, OK, we're going to try to come up with every restriction or, as Deborah said, hoop to make women jump through that we can and see how many of them we can get away with under this new undue burden standard. And they've gotten away with a huge number of restrictions. The Supreme Court really has only found two or three types of restrictions so far to be an undue burden on a woman's rights.

As I said, the spousal consent provision that was in Casey and a couple of years ago, in a case from Texas and a similar case in Louisiana, the Supreme Court found that a requirement that an abortion clinic have to have a physician on staff that had admitting privileges at a nearby hospital was also an undue burden, one because it was utterly unnecessary. You don't need your physician to have admitting privileges to get an emergency patient into a hospital, and because you know, no hospitals in those state would grant admitting privileges. So, it had the effect of shutting down clinics. But everything else, the Supreme Court, under this undue burden standard is said, is just fine. You can, as the world said, you can impose waiting periods,

Mandatory ultrasounds, prohibitions on telemedicine requirements that the state can force you to have a vaginal ultrasound, requirements that the doctors have to give you medically inaccurate information intended to scare you out of having an abortion and, you know, try to basically force you just choose to carry the pregnancy to term. So, the current legal framework actually allows for quite a lot of restrictive laws that all these hostile states have taken full advantage of.

Dr. Palermo: So, you mentioned how Casey kind of set the stage for allowing increased restrictions that states can put on abortion access. What does the current trend surrounding related cases indicate for the future of abortion rights in the US?

Professor Finley: I think the current trend is actually rapidly getting us towards overruling Roe and Casey and perhaps allowing states to outright prohibit abortion. I should clarify the other key part of Roe that Casey kept in place was that prior to the point at a pregnancy that it's viable whether the fetus is capable of living on its own outside the womb, prior to that point of viability, the state simply could not ban abortion.

But now, several states and a very deliberate strategy to try to create a case that would force the Supreme Court to overrule Roe now that the composition of the court has changed under with the appointments of President Trump and the death of Justice Ginsburg, they started passing some laws, basically banning pre-viability abortions, knowing that under Roe and Casey, those laws are unconstitutional.

But hoping that the cases would get to the Supreme Court and the new composition of justices they hope will overrule Roe and eliminate viability is the point before which the state can't ban abortion. So right now, pending before the U.S. Supreme Court, in a case that will be argued on December 1st, is a case from Mississippi called Dobbs.

And so Mississippi passed a law that permits abortions up to 15 weeks. Last menstrual period, gestational age but after 15 weeks bans abortion unless necessary to save the life of the woman. Excuse me, of the pregnant person because obviously a pregnant man would not be able to have an abortion either through the Mississippi law. So that and the Mississippi specifically asked the Supreme Court to take up the question of whether, you know, the Roe should be overruled, and states should be allowed to ban abortions pre-viability.

The other case that's working its way up, Supreme Court comes from Texas, everybody's been hearing a lot lately about this Texas law. Texas passed a law basically banning all abortions after six weeks post last menstrual period, a time at which most pregnant people do not even yet realize that they are pregnant.

And Texas came up with a very devious, sort of shockingly devious way to try to prevent any federal court from declaring this law unconstitutional.

Normally, if the state passes a law, they designate some state official, you know, like the attorney general or somebody to enforce the law. And so, then if you want to challenge the law as being unconstitutional, the way to do it is to bring a lawsuit against the public official who has the power under this state law to enforce that law. But what Texas did with its new statute is it specifically said no state official can enforce this law at all.

We, the state, have passed along. We're saying we are going to enforce it. They said any citizen, any person, anywhere person in New York, the person in Florida person, California person in Timbuktu, it doesn't matter any person can, you know, go after any doctor in Florida who provides an abortion post six weeks and they can sue anyone who helps anyone try to get an abortion in Texas after six weeks. And that includes helping them pay for it, helping them arrange an appointment, driving them to the appointment. And so, they said, well, no one in advance of the law going into effect will be able to sue the stop law because in advance, nobody knows who the person who might try to enforce the law against them will be. And you can't bring a lawsuit against a hypothetical person. You need an actual person who's trying to enforce the law against you to bring a lawsuit.

So, so currently, the Supreme Court let that law take effect. So currently in Texas, all abortion is banned post six weeks pass the last menstrual period. But the U.S. Supreme Court just, I believe, just last week quite recently decided that they would at least take up the issue of whether the United States government can sue the state of Texas to try to challenge this law, or whether no one can challenge Texas law.

So those are so right now. And so, in fact, in the next few weeks before the end of 2021, there will be two major abortion cases argued before the U.S. Supreme Court. And we may see from the questions of the oral argument some insights into what direction the court may be going. But we probably won't have a decision in those cases until sometime in the spring or early summer of 2022.

Dr. Palermo: Professor Finley, can you tell us a little bit about how this Texas law that you've been talking about might impact women and individuals of low socioeconomic status and people of color who are seeking abortions?

Professor Finley: Yes, we've already seen the impact in Texas, by the way, know Deborah, when she mentioned that Planned Parenthood of Western and central New York has already had at least one patient from Texas come to New York. I, it might have been someone who was just visiting, but I wouldn't be surprised if he was someone who was just trying to get someplace where the state law would permit them to have an abortion. So, a law like Texas or the Mississippi law, if it's upheld or any of these restrictions fall disproportionately most heavily on poor women and unfortunately, women of color are disproportionately represented among poor women.

So, you know, these laws that restrict abortion fall more heavily on poor women for multiple reasons. First, the Texas law, in order to be able to afford to travel to another state, you have to have the financial resources to do that. You have to have the ability to take extra time off from work in order to now not just travel 100 or so miles, but to another state or even to fly to a state, you know, far, far away. You have to then have extra resources for childcare, for lodging at the place you are going to travel to. And you know, all of those things cost money. And, you know, many, many lower income women are in jobs with the least amount of flexibility for time off, the least amount of ability to afford childcare or extra childcare.

And also, you know, then the extra time it takes to arrange to find a provider where you don't have all these hoops to jump through often pushes the abortion procedure later into pregnancy, which increases the cost. So, you know, women of women of means women who have flexible jobs can take time off, have private insurance or private money are always going to be able to travel somewhere to get an abortion. But women who don't have those financial resources and flexibility in their life won't be able to.

The Texas law also falls very disproportionately heavily on undocumented women. Women in prison. Women in in ice detention centers, immigration detention centers. They don't have the option of traveling to another state. And even though the federal government is obligated to provide them with an abortion if they're in a federal immigration detention center, the federal government is not obligated to pay for them to travel to another state to get it. Nor is the Bureau of Prisons obligated to take a prisoner to another state and young women, very young women who now in addition to all of the hoops they would have to jump through in getting, you know, either a, you know, a judge to approve their abortion. If the parents won't, they now, you know, just say to them, Oh fine, the judge approved it.

“Now just get in your car and drive to Oklahoma.”

“Excuse me, I'm 16. I'm not allowed to drive.”

And if their grandmother, aunt or mother helps them drive to Oklahoma, they're afraid they might get sued under this Texas law. So, it is. It is an absolute tragedy for poor women, young women and women living in carceral facilities.

Dr. Palermo: Those are some really sobering points that you're making right now. Deborah, is there anything you'd like to add about how these different state restrictions on abortion access affect lower income individuals and people of color disproportionately?

Deborah McDowell Hernandez: Well, I'll just I think Professor Finley did a great job in describing the dynamics of excess or inaccessibility, given the different states. But when you think of geography, there are other things you can think of. There are some cities. 27, to be exact, American cities are considered abortion deserts because people who live in that city have to travel one hundred miles or more outside of that city in order to find an abortion provider.

So, I mean, 27 might not sound like a lot, but within those 27 cities, if you're thinking that some of those women or the folks who are needing the abortion might be black, LGBTQ and the disabled 100 miles is a long way to travel, especially if you don't own your own car and you're trying to, you know, cover transportation by train, bus or plane and get time off from work.

So again, depending on which county you call home, you might be traveling quite the distance. And chances are, you know, if you're undocumented, documented and Latina or Latinx or Black, there still might be the possibility that you might not be able to get time off from work or have the money to get to where you need to be. And then, you know, if you're a young person, you don't have that type of savings necessarily or a credit card or a job to help fund you to get you from point A to point B in the right amount of time before you exceed limits.

So, you know, when I think of the dynamics of someone who lives in a very rural area, maybe you're in a very rural county or the counties that surround you are all quite rural and you might have quite the distance to travel before you come across a medical provider. And then on top of that, a medical provider that even performs abortions is willing to are qualified to perform abortion services. And many patients who see Planned Parenthood, not just New York State, but in other states, Planned Parenthood is the only medical attention that many patients have because they don't see a doctor regularly or because they live in such a remote area, a rural community, and that might be the only time that they are getting any type of medical exam.

Dr. Palermo: Professor Finley, I want to turn back to some of the cases you were talking about, you mentioned the Dobbs case. Can you tell us about that? What is the likely?

Professor Finley: So, it's currently on the Supreme Court docket. What's the likely outcome and what would this mean for access to abortion in the US?

Well, it's always difficult to predict how the Supreme Court is going to rule, but I think in this case when you look at. The fact that there are already four justices that in previous cases have said they think Roe versus Wade is unconstitutional. And have been looking for to take a case where they could make that the majority opinion. And then you look at the fact that, you know, two of the two of the new justices added by President Trump, Justices Kavanaugh and Coney Barrett in many previous writings have expressed.

Let's just say, either in Justice Barrett's case outright, you know, moral and religious adamant opposition to abortion and injustice. In Kavanaugh's case significant legal skepticism as to whether the Constitution protects abortion.

You know, simple counting that seems like, you know, five or six votes to either overrule Roe completely or to substantially change it and permit states to ban abortion prior to viability. If the court says that states can ban abortion prior to viability. You know, that's going to open up all kinds of questions will do. They have to always allow an exception for women's health, or do they have to allow a rape or incest exception? Do they or do they only have to allow an exception when you know, several medical providers say the abortion that the woman carries the pregnancy to term, she will definitely die, and no medical provider in advance will rarely be able to say that she will definitely die if she carries the pregnancy to term. And by the time seer, the serious health complications of pregnancy arise, such as with pre-eclampsia or gestational diabetes. At that point, it may be too late to say, oh well, let's have an abortion.

You know, at that point, the severe damage to the woman's health is already done. And here I think it's also important to link, you know, whether there will be any kind of an exception to a ban on abortion to protect women's health with health equity issues for facing women of color. And for women of color, it is just tragically appalling that the well-documented serious risk to their health that carrying a pregnancy to term can entail.

So that's another way in which any change in the law that permits states to further restrict or ban abortion is going to have a significantly disparate impact on the health of women of color because pregnancy is a far more dangerous than an abortion. And its pregnancy is particularly dangerous for women of color in the United States.

Dr. Palermo: Thank you for reminding us of those morbidity and mortality statistics, and as you point out, the U.S. has among the highest rates of maternal mortality for high income countries, and the disparities between groups within our country are very stark. Turning to New York State now, Professor Finley, can you tell us what legislation has New York State passed or do we have pending to safeguard the right to abortion? And how will these laws interact with the potential erode vision or overturning of Roe?

Professor Finley: New York State has, as Deborah mentioned earlier, the Women's Health Act, which I believe was passed in 2019 and it essentially codifies in New York law the holding of Roe versus Wade, namely that prior to viability, a woman has an absolute right to decide for herself whether to have an abortion, and the state cannot ban it. In New York, law post viability, if the abortion presents a risk to the woman's life for serious health impairment, the state would have to permit her to have an abortion. And yes, that that's protected by statute in New York. So, if the Supreme Court overrules Roe, it would have the immediate effect of saying it's up to each state what they want their law of abortion to be.

So, New York has already said what it wants its law of abortion to be, and that is that women have the right to choose whether or not to have an abortion and prior to viability, the state cannot ban it.

But something to keep in mind. And you know, we can't forget federal politics here and the composition of the federal legislature. If you know, in any upcoming election, whether 2024 or whatever, if Republicans control once again, as they did under a little bit under Trump, the White House, the Congress, the House of Representatives in the Senate, there's absolutely nothing to stop them from passing a federal law that bans abortion in the entire United States. And then because federal law is always supreme over state.

There’s really nothing that would stop a federal government with a Republican in the White House, Republicans controlling the Senate, Republicans controlling the House to pass a federal law banning abortion and federal law is always superior to state law, so the federal law would supersede and make void and unenforceable, New York's law saying in New York, we want women to be able to have the right to decide whether to have an abortion.

So, you know, I relate this to the big filibuster debate in the Senate. You know, the only thing that would stop a Republican controlled Senate, House and White House from banning abortion throughout the entire United States would be the filibuster in the Senate. If the Republicans control the Senate with less than 60 votes, you know, so right now everybody's saying yes in order to secure voting rights and do other, you know, in climate protect the climate and other crucially important things, they want the Democrats to get rid of the filibuster. But I always say, well, OK, but remember, you get rid of the filibuster now when the Democrats are in control, just think what's going to happen when the Republicans are in control again?

So, it's a really complicated issue.

Dr. Palermo: Turning to you, Deborah. Can you tell us a little bit about what Planned Parenthood is doing to ensure access to abortion in New York state as well as other states?

Deborah McDowell Hernandez: Well, I think if I could give them all the would be actions, labels, I would say advocacy, lobbying and education, education and advocacy are very important, especially now because I think many people who aren't necessarily in this circle of reproductive and sexual health or maybe who are not activists really don't realize how great of a threat we currently have in losing access to abortion across the country. So, education is very important in getting the word out to other coalition members.

Our partners in the community, our supporters, be the donors or volunteers or activists getting out there, meeting with our elected officials to let them know how important this is to us and ensuring that we can offer our patients and the community in general, the care that they count on and realizing that many of the people that we are supporting are already in a vulnerable state, not limiting the discussion to abortion, but just simply having access to family planning, care, birth control, contraceptives, sex education in general, you know, testing for sexually transmitted diseases and treatment and things like that.

So, we take special care and making sure that, yes, we continue to provide health care to our patients, but we also need to educate the community on the on abortion, the importance of abortion access, lobby as needed to try to continue to get support from the elected officials because we realize that the true change occurs when policies change. So, we need all of the energy out there. We need our cheerleaders, attending rallies, going to marches and things like that. But we also really need the people, the cheerleaders, who can sign those bills and make them laws on our side to help support the cause.

One of the things that we're supporting right now, all of the affiliates in New York State Planned Parenthood affiliates is an abortion access fund, which would allow the average citizen to designate a portion of their income on their tax return form to abortion access. And then those funds would be distributed to different nonprofit organizations in the state of New York to help people who need funding support to pay for abortion services. So, something like that is a very basic lift.

If we can just simply have that as a box on your tax return to check off. It seems like it would be a win-win. We also inform our supporters of other abortion access funds across the country. We've even done campaigning or fundraising locally to help support many of those access funds in Texas, since the checks in patients are having the biggest struggle or threat right now. So, you know, fundraising as we are able to help Texas and other states, other hostile states since we're using that word elect. And education again and advocacy, those are some of the big things that we're taking on patient advocacy.

Dr. Palermo: Thank you for that you've given us so much to think about today. I wonder. Before we wrap up, is there anything that either of you would like to add, maybe starting with Professor Finley?

Professor Finley: I think I want to underscore something that I just said that I think don't think most people really realize how the right to a safe, legal abortion is under threat to a far greater extent in this country than it's ever been since Roe versus Wade. That is, as I said, when you ask, what did I think was going to happen in the Supreme Court, I think that, you know, by the end of by mid-summer 2020 to the U.S. Supreme Court is highly likely to have said either that Roe is completely wrong or that as long as they, you know, safeguard women's health, states can ban abortion almost at any time. And I think I particularly want younger women to think about this, what this would mean for them because younger women never lived in the pre-Roe world.

They don't know women like I do that or like my mother, you know, who had to go and get illegal abortions and what it was like and how degrading it was and humiliating and dangerous it was. And you know, just what a sort of basic aspect of your humanity gets taken away from you when the government says, you know, basically, we can conscript your body and force you to bear a child that you feel at this stage of your life you can't properly care for or support or to have would risk, you know, the safety of you and your other children because you're in an abusive environment. So, I just want to echo Deborah's call for saying, you know, education and advocacy.

If the Supreme Court overrules Roe, abortion will probably become one of the hottest issues in electoral politics at the state and the federal level, and it's going to take sustained commitment and activism from people who care about women's fundamental humanity and dignity and right to make their own decisions to fight for it. And in the states that are currently restrictive to elect people who do respect women's dignity and humanity and right to make their own decisions.

Dr. Palermo: You raise some really important points there about how common abortion is now and how we take for granted that abortion is health care, and it hasn't always been that way in the US. And as Deborah told us at the beginning of the episode, one in four U.S. women will have an abortion by the age of forty-five. So, it's very common and it's a very safe procedure, and that's something that we kind of take for granted now. But it's something that hasn't always been that way and may not always be that way. But still a very common procedure that women will continue to need in the future. Deborah, are there any final comments that you'd like to leave us with today?

Deborah McDowell Hernandez: The only other thing I'd say is we're very grateful for the support that we receive from the faith community.

Planned Parenthood Empire State acts has a Concerned Clergy for Choice Group, which is a group made up of supportive clergy members from across different faith sectors, and they join Planned Parenthood and other community coalition members in advocating for sexual and reproductive health and safe and legal abortion. So, I think it's pretty powerful when you're able to have a reverend, a rabbi and minister joining you during a legislative visit with an assembly person or a senator to explain why they want the people in their congregations to be able to make the decision and not have it be made for them by a politician.

Dr. Palermo: So, thank you both again to Professor Lucinda Finley and to Deborah McDowell Hernandez for being with Buffalo help cast today. Really appreciate your time and all of your insights on this important issue.

Thank you so much for being with me today. Thank you.

Professor Finley: Thank you. Yes, thank you for having me and for bringing attention to this very important issue.

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Hello and welcome to Buffalo HealthCast, a podcast by students, faculty and staff of the University at Buffalo School of Public Health and Health Professions. We’re your co-hosts, Tia Palermo, Jessica Kruger, Schuyler Lawson, and in this podcast, we cover topics related to health inequity here in Buffalo, around the US and globally. In this first semester of the podcast, we're taking a deeper look at racism and health. We'll be talking to experts around the US as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population, health and well-being. You'll hear from practitioners, researchers, students and faculty from other universities who have made positive changes to improve health, equity and inclusion.

Natasha: Welcome to Buffalo HealthCast. I'm Natasha Allard, a Ph.D. student in the Department of Community Health and Health Behavior here at the University at Buffalo. I'm joined today by an amazing group of women I have had the honor of working with in my past role at Roswell Park Comprehensive Cancer Center. I've seen firsthand how passionate they are about reducing health inequities, especially among Black women here in Western New York. So, I knew we had to have them on the podcast to discuss. Today, we have First Lady Naseary Harris and First Lady Charmaine Geeter, both from the National Witness Project and Dr. Ermelinda Bonaccio, Chair of Diagnostic Radiology at Roswell Park. It is so wonderful having you all here today. So, let's start with some introductions. First Lady Harris, can you tell us a little bit about yourself and your role as a first lady?

First Lady Harris: My role with the National Witness Project is chairperson for FLOW, which is the First Ladies of Western New York. So, I do a lot of work with recruitment, educational programs, navigation and getting the word out to our community about the importance of early detection of breast and cervical and colorectal cancers.

Natasha: That's wonderful. Thank you so much. And for anybody who isn't aware, can you explain what a first lady is and why we use that title for you?

First Lady Harris: Yes, it simply means that we are the pastor's wife. That's how we are addressed in our congregations.

Natasha: Wonderful. Very important role. First Lady Geeter, can you tell us a little bit about your role and who you are?

First Lady Geeter: Hi, my name is Charmaine Geeter. I'm also a pastor's wife. I work alongside with First Lady Narseary Harris. She brought me in to the National Witness Project, working alongside of her with the First Ladies of Western New York. I do the same thing. I help her recruit. I help her give seminars on helping to educate women on getting their breast examinations, make sure that they know what to do on how to give their self-breast examinations, make sure they get their checkups. Also educating, also educating men on making sure to let them know that they, too, can get breast cancer, colorectal cancer, HPV. We do whatever we can to educate. Our community is wonderful.

Natasha: It's quite the heavy task you have taken on, but it's so wonderful. And the work you do is so important. Dr. Bonaccio, tell us a little bit about yourself and your role at Wrestle Power to thank you for having me on.

Dr. Bonaccio: So, I am the chair of diagnostic imaging at Roswell Park. But the reason I'm here today is also for the past twenty-four years, I practiced as a breast imager, reading mammograms, doing any of the images, guided biopsies, MRI, ultrasound. So that's my clinical role, although I've taken on this administrative role and screening mammography has been a big part of my mission here and bringing that to Roswell.

Natasha: Wonderful. Thank you so much. So as many of us know, October is Breast Cancer Awareness Month, and one of the most critically important aspects of awareness is understanding how a disease affects different communities. So today we will address disparities in both breast cancer and breast cancer screening, particularly in the African American community. So, First Lady Harris, I'm going to ask you to dig a little deeper into what the witness project is and why this exists.

First Lady Harris: So, I really got involved when I was introduced to the Witness Project by Detric Johnson, who is now actually the national director. What really caught my attention is the fact that they were addressing all of the concerns about African American women, why they weren't getting mammograms, why they weren't going in for their pap smears. But what really caught my attention was that they were actually coming into the community, coming to where these women are and stressing the importance of early detection. That just really got my attention after finding two breast tumors of my own. There was nobody in my life to navigate that for me. There was nobody that I could talk to, and I was reluctant to talk about it. It was like the it was like sharing that information was taboo or, you know, I know I wasn't contagious, but it was just the fear of the unknown about breast cancer and then having friends who actually had breast cancer and died. So, it was the fear factor. It was. Not knowing, not having somebody to talk to about it, the friends that I had who actually had breast cancer, they were reluctant to talk about it. I guess it just happened to be because of being a pastor's wife, they were more safe to talk to me about it. So, this organization happened. I thought, this is amazing. And what an opportunity to share this information with other women and help navigate them and guide them through the process that I felt so afraid of and intimidated by.

Natasha:  That is wonderful. I really appreciate you sharing your own personal story and your passion just shines right through. So, we really thank you for sharing that. First Lady Geeter, do you have anything you want to add about why the witness project is important to you or the work you do?

First Lady Geeter: One thing that was so amazing. The one thing that, we use a term in the church, was meeting people at the point of their need. It was like we come to you. We don't wait for people to come to us. So church is a big gathering place. It's like the family is already there. And so, it's almost like a place of trust. And the one thing that I find out, find out about our culture, we don't tend to share. So, we don't tend to find out if my grandmother or my auntie may have cancer. So that is a big factor to know what is in your blood line. So, if grandma may have had cancer, then it's good to know that I need to have a mammogram earlier than 40. So, education is the key. So, when we can bring these educational seminars or educational talks to the church, to the place where they already are, then that is the key. The key is to educate so that we will know these things so that we could do better. So, I just felt like it was just phenomenal to know that we can bring these things to where they are. So, like we say, we'll go to your family reunions. We will go to your apartment complexes. We will go to wherever you are. We will bring these things to you.

Natasha: That is amazing. I love your point about knowing your own family history and your personal risk. And you both have just made such a great point about going to where women are or where people are for screening. I think that's such a wonderful approach. So, let's transition a little to understanding disparities within screening for breast cancer. Many different studies over the years have found different racial or ethnic and socioeconomic disparities in actually utilizing screening mammography. This has changed over the years. There's been some great headway is made, but of course, our work is never done. So, we're going to spend a few minutes first diving into what breast cancer screening is and why it's important. So, Dr. Bonaccio, we see studies and health communications use terms and phrases like mammography, annual mammograms, breast cancer screening somewhat interchangeably and different ones in different places. But in an effort here today to potentially overcome health literacy barriers, can you boil down what those words mean?

Dr. Bonaccio: So, a mammogram is a type of X-ray. It's a very low dose x ray of the breast. And in general, when we talk about screening for breast cancer, we are talking about mammography. And it gets very confusing because 3D mammography or tomosynthesis or other terms that you might hear, and those are essentially a newer, improved mammogram. So, we typically talk about screening mammography when we're talking about screening for breast cancer, because that is the test that has been proven in multiple different types of studies, randomized controlled studies, case control studies over the years to lower your risk of dying from breast cancer, up to 40 percent decrease in mortality with women when women are screened with mammography. There are other screening tests for breast cancer usually reserved for women who are at high risk for breast cancer, such as screening breast MRI or for women who have dense breast tissue such as screening ultrasound. The key part of screening is a test we do on a regular basis in this case annually to look for cancer that's not symptomatic. So, we're trying to find a breast cancer before you can feel it. That is the ultimate goal of screening so that we have better chance. preventing death from breast cancer. 

Natasha: That was a great explanation, it makes it a lot easier to grasp on to, I think. Can you briefly tell us what are the current mammography guidelines? So, who is supposed to get one and when?

Dr. Bonaccio: So, for average risk, women, women who do not have a family history or any of the mutations in mammography should start at age 40. And we follow NCCN guidelines, which is the National Comprehensive Cancer Network that we belong to as Roswell Park. So annual screening mammography beginning at age 40. We follow those guidelines because frankly, that saves the most lives. But as First Lady Geeter referred to, it is important to know your family history and women who have a strong family history of breast cancer or women who are known to be mutation carriers, then we will start screening mammography at a younger age and potentially do one of those other screening tests that we were I just mentioned.

Natasha: Thank you, First Lady Harris and First Lady Geeter. Do the women you meet in your work with witness project typically know these guidelines?

Natasha: Do they know they're supposed to have a mammogram but just maybe aren't getting one or do they not even know? Is the awareness not there yet about the age you're supposed to get screened?

First Lady Harris:  So typically, I think the I think the awareness may be there in a lot of cases. I think the trust, but I think the fear factor. I think the lack of insurance sometimes and if there has been a family member who had it, the fear of finding out that they might have it, and that is a death sentence. So, I think knowing that mammography is helpful, the importance of it sometimes, I think is not there due to the lack of education about what why it's important and the possibility of early detection not being a death sentence for you. So, it's a combination of things. But I think by and large, mammography, the word if you say what is a mammogram and who gets it, that knowledge is there, I think more often than not. But the navigation of getting one, the importance of knowing that could possibly save your life is not always understood in its entirety.

Natasha:  Got it. That makes a lot of sense. 

First Lady Geeter: I also think that sometimes they get mixed signals. I think lately I've also been hearing that a woman should get their mammograms at 50. I have heard that. I've actually heard it advertised on TV. I also don't think that they always know that, that if there's a history of breast cancer, that they should get a mammogram earlier. So sometimes I think that sometimes there is different things that are being said and that causes even more of a distrust when everybody not always saying the same thing. And that's where you get that distrust -- when they hear several different things.

Natasha: Very eye-opening I could definitely see that being an issue.

Dr. Bonaccio:  And the family history piece, I think is very important. More recent data has been showing that there appears to be an increased incidence in the BRCA and mutations in African American women. So, knowing that family history and potentially if it's significant, getting tested, I think is really key to potentially starting younger and doing more than an annual screening mammogram, potentially having an MRI. So that information is really very important as well. 

Natasha: It's interesting. First Lady Harris, you mentioned the fear associated with if a family member had or died of breast cancer. I was just listening to a different podcast; Freakonomics episode called The Ostrich Effect. And they were talking about how specifically in African American women, but many other women as well. Studies have shown that having a close loved one who has breast cancer or even dies of it, kind of just the opposite of what you would think. It makes you not want to get a mammogram. Can you explain that a little bit? 

First Lady Harris: Because, again, we go back to education and navigation. If people when they hear that, they automatically assume. So, remember early on when I said how I got involved with that, with the witness project, I found two tumors in my own body, in my own breast.

The first thing that you think is, oh, my gosh, this is a death sentence. So, when a family member is diagnosed with breast cancer and they die, people tend to…My experience has been they don't want to know they got it, if they got it, they're going to die. So let me just live my life and just the way it is, because I'm going to die of breast cancer. So, there is a fear of the unknown. There's an assumption that if a family member dies with breast cancer, that's what's going to happen to them. So, they just kind of accept it as this is the way it's going to be, which again, is why it is so important. The work of the National Witness Project, getting to those women, getting to those younger women, giving them the gift, giving them knowledge about breast feeding. We know we've learned through the different opportunities of being educated, even through Roswell and the opportunities that they've given us, understanding the importance of early detection, understanding how breast feeding in our and our community changes the risks of breast cancer. So, all of these things are important and helping them to navigate the system, understanding why it's important for you to get a mammogram, understanding that because your loved one died of cancer does not mean it's a death sentence to you if it's detected early.

But the fear is, if it happened to Betsy, if it happened to Grandma June, I'm going to die, too.

So why bother? 

Dr. Bonaccio: I so agree with First Lady Harris about the importance of navigation and education. And it's not just for the screening piece of it, because a lot of the data surrounding survival disparities in breast cancer for African American women is actually even after the mammogram gaps in care following up on an abnormal mammogram, making sure that they receive adequate treatment and complete all the treatment. And when you read it, how we can improve this now, it always seems to come back to navigation, culturally competent education, exactly what you're saying. I mean, what the work the witness project does.

Natasha: Great points. I was actually just going to bring up a statistic from the American Cancer Society that Black women are 40 percent more likely to die of breast cancer than white women and are twice as likely to die if they're over 50. So, I'm really seeing that statistic kind of come to life, as you all are discussing, because you have Dr. Bonaccio, who has some of these medical facts about the importance of early detection, and then First Lady Harris and First Lady Geeter—your passion is really to get those facts to your communities and make sure people know that early detection means breast cancer doesn't have to be a death sentence. First Lady Geeter, you've brought up mistrust a few times. Do you want to talk about that a little more? Can you explain that a little more, what you see?

First Lady Geeter:  Yes, our community has a lot of mistrust and it's very we're very apprehensive about taking part in studies. And I think that if we were able to get our community to take part in studies, we could probably gain and know a lot more. But because of things that have happened to our African American community in the past, it is so very hard to get us to take part in studies because as we know, that has not always been the case about African Americans having breast cancer or dying in breast cancer. We were not always the leading and death of breast cancer. If we could just build the trust in our African American community, I think we could see a change in those numbers. So we're just hoping through the National Witness Project that we can start to build trust in the African-American community to take part in studies so that we can start to see these numbers change.

Natasha: Thank you for sharing that. Here at UB we have a health disparities class within the School of Public Health. And one of the things we discuss is how race is often acknowledged as something that contributes to disparities when in reality racism should be discussed and some of these historical and current contextual reasons for this. So, would you agree that that's something you're seeing with the women you work with?

First Lady Geeter: Absolutely. 

Natasha: Absolutely. So, I want to circle back a little. Everybody has brought up navigation a few times. I'm looking right now, it's a Susan G. Komen list of some various barriers that are current and tangible that they have identified existing for mammography. So, I'm just going to quickly run through some of these and then I invite anyone to weigh in, and if you have seen these as a barrier and how different organizations or policies that you have worked with are trying to overcome these. And we've mentioned a few already. So, we have cost concerns or lack of adequate insurance, lack of having a primary provider or an OBGYN to make referrals, different health literacy or educational issues, childcare issues, not being able to take sick leave or miss work, fear of bad news, fear of a painful mammogram, cultural or language differences, and then a lack of education, which we have discussed greatly. So, what does the witness project do for some of these maybe like insurance or missing work or transportation?

First Lady Harris:  So as far as transportation, we provided it free of cost, free of cost.

If there is no insurance, we help them to get insurance, literally walk them through the process. If they need help with childcare, we make that happen for them, free, free of charge. Everything that we do through the project, it is zero cost to that family. We will educate them. If there are five people, we literally will do a witness project, educational program for a family. You've got your aunt, your uncle, your aunts, uncles, your grandma, your nieces and nephews, your children. We will do a live program for you. And now, because of COVID, we will even do it virtually. If they don't have access to Zoom, we use our own personal zoom to bring them in, to educate them and to navigate them. We will literally hold their hands and take them to an appointment, make the appointment and take them to the appointment. If there is a fear of that they have a bad experience with a primary care, we will assist them with finding a primary care doctor. If there is a breakdown, if somebody drops the ball with their OBGYN, we are there to navigate and help them find someone that they will feel comfortable with. So, we try to eliminate whatever the barrier is. Once it's brought to us at once, it's brought to our attention. We will seek out a way to eliminate that barrier. 

Natasha: So, you really do it all. Full suite of services.

First Lady Harris: One stop. 

Dr. Bonaccio: Just a couple of things to add as far as the cost concerns, even separate from our partnership with Witness, we're actually able in New York State, we have Cancer Services which will cover a mammogram for uninsured and underinsured women. So, if you call for an appointment at Roswell and you don't have insurance, we can connect you with cancer services program, which is a wonderful program. And for those that are insured in New York State, there's not even a copay for a mammogram, for an annual screening mammogram. So, because those 10, 15, 20 copays can add up. So, I think that's one thing to keep in mind. And you don't necessarily need a primary care doctor to come and have a mammogram here. So, I think that in general, we're trying to remove as many barriers as we can for screening.

Natasha: That's so wonderful. Actually, I was just going to ask this. Can you explain briefly how is Roswell connected to Witness Project?

Dr. Bonaccio:  Oh, my gosh, we have such a wonderful long history with Witness project. So, Deb Erwin, who was she's a Ph.D. who was the co-founder of Witness Project in Arkansas, was recruited by Roswell to come here and then set up that program here. So, it's been a long partnership, but when we opened up our community screening program in twenty sixteen, our partnership grew and that we now navigate women to Roswell for their screening mammogram. We will have designated screening days for when this project this summer in the weekdays and summer on Saturdays to again improve access, decrease barriers. But it really has been a long and wonderful partnership.

First Lady Harris: And we certainly appreciate that. We appreciate that. And the fact that they have partnered with us for the One-stop with Roswell has been a true blessing so that we can eliminate the fears. Don't forget women that we were working with, they had a fear of going to Roswell because the only thing they thought when they thought Roswell cancer, that's where people go who have cancer and what this partnership has done, and to partner with the witness project, has changed a lot of that concern with the women in our community. Now, we have women when they find out that they can go to Roswell for a mammogram. They're eager to do it, they want to do it, and especially because of the partnership that Roswell has with the National Witness Project, see our community trust the witness project. They trust us. And so, when we say, oh, yes, you can go to Roswell, we will take you there. And then Roswell’s commitment to our community, to the people that are underserved, who don't have protection, who do face a lot of fear and a lot of rejection when it comes to the medical arena. They are helping to eliminate some of those fears and doubts about where they can go. And are they going to be treated with respect? It's a big difference. And so, we're grateful, the Witness Project. We're grateful for our partnership with Roswell and this beautiful doctor she has…

Let me tell you let me just tell you, when we went there for this last event for Channel four and Roswell, that partnership, she told me, she says, Lady Harris, I would be so honored to be a part of your presentations that you do with your congregations and with the people that you are going out to do the educational programs with, to share some more of the information and to dispel a lot of more of their doubts and fears about cancer and about Roswell and getting more educational from that in, you know what I mean, to put a friendly face to the medical side of it all. So, we are truly grateful to her. She's an amazing partner.

Dr. Bonaccio:  Thank you so much for the kind words and I mean every one of them. I'm really looking forward to presenting at any of the programs where it would work for me to join. I really, I'm really looking forward to that. 

Natasha: So, this is wonderful. Community partnerships like this really are encouraging and inspiring. And I love to see groups like this get together and share their passions, especially because … kind of the flip side of this. I have another American Cancer Society stat that a third of African American women have reported experiencing racial discrimination at a health provider. First Lady Geeter and First Lady Harris, is this something you are aware of? Have you seen or heard from women?

First Lady Geeter: I have heard on different occasions where they feel like they have been treated differently, don't feel comfortable. So, they just they just do not go to a doctor.

They choose not to. And it's just not a good feeling. And I mean me myself and this happened to me where I feel like I have had to change to a different doctor, especially now when I've gotten to more of a mature age where my doctors have retired, and I have to go to choose another doctor. And I don't like the way I have been made to feel and have been on the hunt for a doctor. It's very disheartening. And, you know, you know, the feeling is just something that you feel in your gut. And it’s there, it is just there.

First Lady Harris: You know, I had an experience as well with one of our friends who went to go to her OBGYN and then with, I think, her primary care as well, an African American sister, she told the doctor that she found a lump and wanted them to check for her to check for it. And they didn't do it. They told her, oh, you're fine. I couldn't believe I was actually hearing her say that. She went back again, and she said, I have a lump in my breast. And the doctor still refused to examine her. She went back a third time and said, I need you to examine me. I feel a lump in my breast. So finally, she said, Can I show you where it is? And the doctor says to her, according to her pointed out point, the area where it is, she did that. And then the doctor touched her breast and found that there was a tumor there. When I heard that, it almost brought me to tears because this happens a lot more frequently than we even know, because instead of saying something about it, the person, the woman, she just clams up and just says, I'm not going to be bothered. Why bother? And so that's very, very disheartening. And this young lady, this happened to her about a month ago. I'm not talking about something that happened last year. I'm not talking about something that happened a couple of years ago. This happened 2021. And it happens. 

Natasha: First Lady Geeter and First Lady Harris. I really appreciate you sharing those really personal and honestly horrifying stories. And I'm sorry, and I thank you for bringing awareness to that and for speaking out.

First Lady Geeter: I have had an experience where I had a lump in my breast, and it ended up being fatty tissue and I actually had it removed. And when I when I had it removed, I was told that it was a possibility that it would come back, and it came back, and it was and the removal was very it was very painful. And it did come back. And I went back to the doctor because it came back so quick. And his response to me was, it's because of the kinds of food that you all eat. And I, I mean, when I talk about it tears of well, up in my eyes. Tears welled up in my eyes and I asked, did I ever give you a list of the food that I eat? I said, you don't know what I eat. And I was insulted. 

First Lady Harris: I guess so.

First Lady Geeter: And I never have gone back and, you know, and it's still there and hasn’t gotten any bigger. But at this point, if I ever have to have it removed, I will search out for another doctor because I was just so insulted because I felt like he was telling me it’s the food that African Americans eat that is causing this fatty tissue. 

Natasha: That is heartbreaking and unacceptable. And I honestly don't have words. I have chill as you're telling that story. It's truly an atrocity. It's truly an atrocity. When we look at addressing racism and discrimination, it's hard to even know where to start. But Dr. Bonaccio, what role do health care providers, at a bare minimum, play in addressing racism and discrimination in a medical setting?

Dr. Bonaccio: Well, first, I'm so sad to hear these stories, but unfortunately, I'm not surprised to hear these stories. I mean, I think with any problem, right. First thing we have to do is acknowledge it and talk about it. And that's why I was so glad we're having this conversation.

And I do feel like that we're having more of these conversations over the past two years in the medical community. And that is going to be a huge piece of addressing it. It is going to take time. But we talked a lot about educating African American women to have a mammogram. But we as medical care providers have to educate ourselves to learn how to address these issues to teach young physicians and practicing physicians and providers about unconscious bias, about culturally competent conversations. I mean, we have a lot of work to do. But I am heartened, as disheartening as these stories were, I am heartened by the fact that we're talking about it more so than I've been practicing for twenty-four years. And the intensity of the conversation that we're now having in the medical community brings me hope that we will then start moving towards solutions.

Natasha:  Absolutely. Talking about this is so important.

Dr. Bonaccio: First Lady Geeter’s point about it's not just clinical trials, but we need research in this area as well. I was sort of as I knew this podcast was coming, was doing some research and focus group research is important, too. There was one study that showed, for example, that African American women require more education once they're diagnosed with breast cancer, more information than potentially on non-African American women do. And it makes sense to me, right. If you're not trusting of the system, if you're worried about racism, you're probably going to have more questions in the information. So, getting that information out to providers I think will help to as we get more research in this area.

Natasha: Thank you. As we come to a close today, I'm going to ask each of you to just share one final message that you would want to send either to women of breast cancer screening age or this podcast is listened to by a lot of public health students and faculty and professionals. So, either people in the field or women who need to get mammograms, what is a final Take-Home message you want to send? First Lady Harris, we can start with you. 

First Lady Harris: OK, so what I would like to be able to take home with them is the importance.

Again, we can talk about early detection, how important it is to get that mammogram, how vitally important it is to talk about it in your family. It is so important. And if we could just get that message out there for the screening of breast cancer early, I think that it would help to change all. So, the statistics will change greatly, I think if we could just get that information out, the education out there about early detection.

Natasha: Thank you, Dr. Panopto. I'll have you go next and then we'll close with First Lady Geeter.

Dr. Bonaccio: One message I always like to get out when I'm have the opportunity is that most women who develop breast cancer actually don't have a family history of breast cancer. So just to remind people that our biggest risk factor is being a woman so that even if you don't have a family history, you should have your annual mammograms starting at age 40. But I like to say that along with the fact that it is still so important to know your family history for the reasons we've talked about earlier, so that potentially you can get screened at a younger age and with other studies in addition to the mammogram. But that's an important take home message for me.

First Lady Geeter:  Mine is always if you're proactive now, you won't have to be reactive later.

Natasha:  I love that. It's powerful, succinct, and it sums up everything we've talked about. Well, everyone, I truly appreciate your time. This conversation was powerful and insightful, and I really think it was valuable. And I hope, I know, that everyone listening to this podcast will feel the same. So, thank you very much. And I hope everybody has a wonderful rest of your day. 

First Lady Harris: Thank you for having us.

Dr. Bonaccio: It's such a pleasure working with both of you. Every time I have the opportunity.

Natasha: This was wonderful. Everyone, I really, really appreciate it.

This has been another episode of Buffalo HealthCast. Tune in next time to hear more about health equity in Buffalo, the US and around the globe.

All content © 2021 Buffalo HealthCast.

Hello and welcome to Buffalo HealthCast, a podcast by students, faculty and staff of the university at Buffalo School of Public Health and Health Professions, we’re your co-hosts, Tim Palermo, Jessica Kruger and Schuyler Lawson. And in this podcast, we cover topics related to health equity here in Buffalo, around the US and globally. And the first semester of the podcast, we're taking a deeper look at racism and health. We'll be talking to experts around the US as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population, health and well-being. You'll hear from practitioners, researchers, students and faculty from other universities who have made positive changes to improve health, equity and inclusion.

Tia: Hello and welcome to Buffalo Health Care. I'm your co-host here, Palermo, and I'm here today with the doctor of Jericho Road. Welcome, Dr. Glick. Thank you. Here. Thank you for this opportunity to start us off. Can you tell us a little bit about Jericho Road and your role there?

Myron: Sure, yeah. My wife and I started Jericho Road in nineteen ninety-seven. I'm a family doctor. And when we started, our original purpose was to provide excellent quality family health care to folks on the West Side who needed it, whether they had insurance or not, and especially Medicaid and uninsured folks. And that was back in ninety-six, ninety-seven. So almost twenty-five years ago. Since that time we've grown a lot. And today we're a pretty large organization in Jericho and Buffalo. I'm still a family doc. See patients deliver babies and I'm also the CEO of the organization.

Tia: That's great. Yeah. Can you maybe tell us about the different parts of Jericho Road and what the different projects and locations do?

Myron: Sure. So I tell folks that we basically do five things at Jericho.

Our main thing is we provide primary health care, medical care to folks here in Buffalo, regardless of what their insurance status is. We have five health centers in Buffalo that provide primary health care and about 40 doctors and nurse practitioners. And so we see a lot of patients and many of our patients, over 50 percent, come to us as refugees and immigrants from other places. They've moved to Buffalo for whatever reason. And then we have lots of folks who grew up in Buffalo on the east and west side of Buffalo, and they become our patients.

The second thing we do is we long ago realized that providing medical care isn't really enough if we're really going to have an impact in people's lives. And so we've started a number of programs that are tied into the medical care that we provide that address or try to address some of the root causes of why people are sick and really the social determinants of health. We can't do it all. But these programs are our logit programs that really impact people's lives where they're at.

The third thing we do is we, in partnership with the University of Buffalo, have a family medicine residency training program at our site, one of our sites. So we know every year we get a three-year training program. Every year we get four new recent medical school grads who want to learn about what it means to be a family doctor. And they're here for three years with us. So like right now, we have 12 family doctors in training. And that's a wonderful opportunity for us to sort of give a little bit of our DNA to other doctors. And some of them may work for us in the future when they graduate and others will go other places and make a difference and take a little bit of what they learned with us to those places.

The fourth thing we do is we run a homeless shelter called VVA. And this homeless shelter is specifically for asylum seekers who have come to Buffalo, come to this country, mostly crossing through the southern border. Many of them have had harrowing journeys that have lasted years to get here. And they're looking for a home for their families, either here or in Canada. So every night we shelter probably one hundred to one hundred and forty people at VA and we provide medical care, trauma-based mental health care and legal advice to these folks in addition to shelter and the physical needs that they have.

And then the fifth thing that we do is one that I mean, they're all exciting to me because I'm involved in all of these options But we have a global health program through Jericho, where we followed some of our refugee friends back home to Sierra Leone, to the Democratic Republic of Congo and to Nepal, and we have we run we operate five health centers in those countries that  are fully staffed by local folks from those countries. We provide some financial support and operational support, but it's really locally run and operated in the blood. And we're almost seeing as many patients in other countries as we see now in Buffalo. So that's sort of a quick overview of what we do at Jericho.

Tia: Right. Thank you for that. It was really great to hear you talk about the social determinants of health in our school of public health and health professions. At the University at Buffalo, we talk a lot about how social determinants of health and upstream factors really affect the access to care that people have as well as their health outcomes. So it's really nice to hear you talk about how you're bringing both sides together in the provision of health care and you're doing so many different things. It's very impressive.

We brought you here today to talk about Jericho, a Jericho Road role in the effort to assist Afghan evacuees who are now arriving in the United States. I think there's about three hundred and fifty evacuees expected to be arriving in Buffalo. So can you start out by maybe telling us a little bit about the standard refugee resettlement program? So what do refugees get when they get here? And how do refugees differ from other types of immigrants in terms of their legal status?

Myron: No, that's a good question. So refugees are folks who have had to flee their homeland because of war or some kind of horrible trauma and are now being resettled in another country. They're not choosing to leave their country. They're fleeing for their lives. Many have lived in refugee camps across the world and many have become certified by the UNHCR United Nations high command of refugees as official refugees and whereas an immigrant would be someone who chooses to come. And they're not necessarily fleeing refugees fleeing for their lives. And then you have asylum seekers who often really are refugees if they're fleeing the same set of circumstances, they just never got certified by the UNHCR. And so they have to find a different way into the country. So if you think about folks coming to the United States, I would say there's a category of refugees which are folks that the United States has agreed to take in. And when they get here and they're assigned to Buffalo, they're on a pathway to citizenship that will hopefully culminate within six to seven years of them becoming actual American citizens. And when they arrive here, they receive a significant amount of support for at least the first three to six months through the federal government. And that support is channeled through local refugee resettlement agencies in Buffalo.

We have four of them. We have the International Institute, Jewish Family Services Journeys and Refugee Resettlement Services and Catholic Charities. And those organizations get money through the federal government and through the state to resettle refugees to help them find an apartment, to help them get to the doctor, to help them apply for Medicaid and social services and find that first job. That's sort of the pathway that Jericho probably has. Ninety five percent of the folks we see from other countries come as official refugees. We step in and provide the initial medical evaluation within 30 days for these folks and then we become their medical home so that many of those you know, we're the only doctors we've ever seen and they've been here 10, 15, 20 years. We've become their home for their medical care asylum seekers. It's much different. They're coming in through a whole different pathway and they don't get a lot of the services that are offered to the refugees and then immigrants. A totally different story. The challenge with the Afghan evacuees is they're coming in on a different sort of. Under a different sort of legal status that's much more similar to asylum seekers than it is to the official refugees. And so right now they're being promised like one month of services through the federal government that will be given to the refugee resettlement agencies. So there is a real need for our community to rally around supporting the refugee resettlement agency so that they can actually provide more of a standard amount of services for these Afghan folks who are fleeing their country.

Tia: What are some examples of the medical needs of the refugees that you see in your program?

Myron: So a lot of these folks come and they maybe have had some evaluation in the last year or so, but they're fleeing situations that set them up. I mean, first of all, many countries that are coming from don't have the resources to address problems that we take for granted here. Problems like hypertension or diabetes, maybe they don't have access to insulin or medications. Some of them have had trauma because of war. Maybe they lost a limb, but they never got physical therapy or a prosthesis. Some of them, we still see people today who were affected by polio when they were kids and they can't walk or they've lost the use of a limb. So we see children that have had autism or severe developmental disabilities that never got any resources. So we see, you know, there's a real opportunity to get people plugged in to our American health care system that has more resources if you at least if you have access. And so we do that. And then we also have an obligation to screen folks that are coming here from a public health standpoint for things like TB and and HIV and all kinds of infectious diseases and offer treatment so that, for instance, you don't have someone with active tuberculosis who's in the community and potentially spreading it to other folks. And then there's just basic stuff. Getting women who are pregnant set up for prenatal care, getting folks, you know, there's children shot so they can attend school. So we it really is a big challenge for us to do that care and do it well. And given that, we'll probably be getting usually the refugees kind of come in gradually over a year basis, not 350 people at one time. So we'll be it'll be a little bit of a challenge for us, but we'll be fine. We’ll do it.

Tia: You mentioned some of the issues that you might see with people coming from different countries. So in addition, when you're providing the medical care, in addition to the language barriers, what are some of the other challenges that might be more prominent in communities that are coming to the US for the first time or that don't have that medical home that you were talking about?

Myron: You mean conditions that we see or you mean like one of our challenges to try to get them good care?

Tia: both.

Myron: Well, I mean, I would say that probably one of the biggest challenges is helping folks recognize that the trauma that they've experienced is potentially really affecting them, maybe even causing some of their physical symptoms and getting folks to recognize what depression looks like and what, You know, post-traumatic stress disorder is. And, you know, the. From a doctor's standpoint, in many of the countries we take care of folks from, there's not a word in their language to even say what depression is like. There's not a comparable word for PTSD or anxiety. And so these folks have a whole different way that they sort of make sense of those symptoms. And so a huge challenge for us is to understand the cultural difference between how we look at mental health and how, say, someone from rural Sierra Leone looks at mental health. And if you don't bridge that gap, you're just kind of stuck because, you know, what's the use of giving them medication for and for depression or setting them up for counseling if they don't really understand the basis for it. So I think even more challenging than the language barriers is helping people understand the cultural context of the different symptoms and illnesses that we identify with. And then once I mean, once they do, then getting them good care. It's not easy to come here as a refugee or an asylum seeker or an Afghan refugee evacuee. You've seen so much trauma more than most people should have to bear. And then you're coming to a new place with a new language, you know, new weather patterns, everything's new and it's very challenging. So we see a lot of mental health illnesses down the road downstream after we start to really get to know folks.

Tia: Yeah, I think the work that your organization is doing is so amazing and important, coming to a new country and having only a few months of financial support and then having to make your way on your own and navigate new systems. It can be very confusing. I mean, I'm speaking as an American woman. I've lived abroad in another high income country. And even for me, with all the assistance and support that I had, navigating another health care system was very confusing for me. And I had a lot of support. So I can't imagine what it's like coming to a country and having to navigate that with less support.

So for your organization to come in and support these families is really amazing. One of the projects that you have is called Priscilla Project. Can you tell our listeners a little bit about what that project does?

Myron: So the Priscila project provides support to our pregnant moms, especially refugee moms who are new to this country and especially women who grew up here in Buffalo, but maybe this is our first pregnancy or there's other challenges that you're overcoming with this pregnancy. And so we surround these women with support, do home visits to make assessments, provide prenatal education, provide.  Birthing classes, breastfeeding classes, those that need a doula, we provide that either in the language of the country they're from or in English, and then we provide interpreters, live interpreters at the births, which is a huge improvement over, you know, using a telephone to interpret or a family member to interpret at the actual birth of the baby. And then there's some follow-up after the baby's born. So it really is a hands-on way of helping folks navigate what can be a challenging time.

We will talk about health inequity. One of the things I've looked at over the last couple of years with our folks at Jerrica Road is because we're a federally qualified community. Health Centers are 17 measures that we have to report to the federal government on every year. And one of those measures is low birth weight. So of the babies who are born at Jericho, we deliver about four hundred babies a year. How many of them have birth weights under twenty-five hundred grams? And I'm very happy that we don't see a racial disparity in birth outcomes at our health center. So in other words. Black folks and white folks and refugees all are equally prone to having low birth weight babies for the most part, and that's not what the literature would show at large. And I believe that the Priscila project, along with excellent prenatal care and the kind of care that we give it, Jericho, we really go after people. If they don't keep their appointments, we will run them down, that kind of thing. I think that's why we're seeing the inequity overcome. I have no doubt that the racial inequities in health that we see if we were intentional across this country at providing the extra resources are more like equity, I think that, in other words, do not necessarily treat everyone equally, but put extra resources to where the need is. You can make up these gaps. And I think that's what the Priscila project is helping us make up that gap or close the gap with regards to the outcomes of the women that we deliver it.

Tia: That's such an amazing success story, it's so great to hear how you've identified this issue in the different ways that you've worked to empower women to have healthier pregnancies, and then you're demonstrating that it works with the hard data in these low birth weight indicators. I mean, it's great to see it all come together that way. And low birth weight is important not only for the survival of the infants, but addressing low birth weight can have implications down the road for the future well-being of children. So it's a really important program and really great to see the success of that program.

You've talked about what your organization does. Can you maybe take us back a little bit and tell us how you got started and why you do the work that you do?

Myron: Yeah, so I, I. Sort of had a long journey to come to Buffalo and to do this work, my parents were Amish and my wife's parents were Amish. We were born in Lancaster, Pennsylvania. I end up spending 10 years of my life, 11 years of my life in a Central American country called my parents were missionaries there is there that as a kid that I got this interest to be a doctor and I think I was because of exposure to the health needs in that country. So when we got back to the United States, still part of the Mennonite community, I didn't really sort of didn't have exposure to the way the poor were treated here in this country until I got to medical school at the University of Buffalo and specifically in my third year of medical school. So all along I was thinking, I'm going to be a doctor in another country and address the health needs that I saw there. But in medical school here in Buffalo, doing my third and fourth year, I was honestly shocked by the way the poor were treated on the clinical rotations that I did at EMC and other places where there's no question that there were basically three standards of care for folks in Buffalo. If you had good health insurance, you saw a completely different set of doctors and were treated differently. And if you had Medicaid, you saw residents, medical students in clinics across the city, mostly in big hospitals, never seeing the same person. The next visit will always be someone different. You'd have to wait a long time, handwritten notes, teaching opportunities all the time. And then if you had no insurance, basically didn't access the system at all unless you were really, really sick. And then you went to the emergency room. And it's a generalization, but honestly, that's the way it was. And I'd like to say that it's that much different, but they're still is a lot of that, you know, going on in our nation and in Buffalo, still twenty-five years, 30 years later. But anyway, out of that experience, I was like, it kind of changed me. I got basically the call to stay here in Buffalo. I went away for residency then came back in ninety-six with the vision of starting a medical practice on the West Side in partnership with the local church I was a part of. So we did that and. You know, it was that my motivation was to try to create a system where people were treated fairly and equally, regardless of what their health insurance status was, whether they're rich or poor, bring folks together and try to provide the same care. I always said whether it's the president of the United States or the Somali refugees off the plane, if they come to Jericho, we're going to try to treat them the same way. And the motivation for this is really out of my faith. I believe in following Jesus seriously and believe that at the core of my faith is this idea of I'm supposed to love God, I'm supposed to love my neighbor and my neighbor is anyone I mean, who's in need, whether here in this country or some other place. And if I, you know, as a doctor, since I'm a doctor, then that means how can I make a difference medically for this person? So this idea of loving your neighbor, doing unto others like you would want them to do to you, how would you want your mom to be treated is sort of the challenge I would give folks at Jericho. And we've really tried to lead the organization that way from the very beginning. We started out as just my wife and I part-time secretary and a part-time nurse. First week we saw three patients, a mom, and two kids, and the first 10 years were really tough. A lot of challenges financially because as a private practice, taking care of mostly folks with Medicaid or no insurance, there's not much money to be made doing that. So financially, it was a big challenge. But gradually, you know, gradually we just came together. I think, you know, some changes in Medicaid reimbursement, managed care, Medicaid, getting a bunch of other people who were mission-focused like I was to join us. And I mean, the need has always been there. There's always patients in Buffalo that need this kind of care. And so gradually we grew eight, nine years ago, we became a federally qualified community health center. And that then finally solved the financial challenges for the basic stuff that we do because we get a lot more reimbursement for Medicaid and Medicare and uninsured folks now. And so it gave us that foundation to be able to really grow. And we have so and we continue to try to go after the folks who need the care the most. And we continue to try to bring people together since we have a very diverse practice. Lots of lots of you know, our staff is incredibly diverse and reflects the community that we serve. And so. Yeah, so that's why we will be celebrating twenty-five years next May.

Tia: Congratulations, that's amazing and such a powerful story. Thank you for sharing that with us. Going back to the Afghan evacuees, Can you tell me a little bit about how the different resettlement agencies are working together and working with Jericho Road to address some of the needs that these new arrivals will have?

Myron: So I think it's really cool. All the refugee resettlement agencies are coming together along with Jericho Road, So there's five organizations who've come together and are intentionally pooling our resources to make this work, because like I said earlier, the federal government isn't providing much support for these folks when they arrive. And so the typical refugee resettlement process, it would be very truncated unless we all work together and unless the community really supported it. And so instead of competing among each other, I think it was very wise to bring everyone together. And so we're asking the community if they're interested in donating money or their time or resources to this effort to go to the website WNYC which is our five organizations together, and there they'll find resources with regards to how they can donate time or money or effort. And so, yeah, you know, our road specifically Jericho roads role will be to provide the medical care. The other four organizations will provide housing and get folks plugged into the community. And so I think working together with folks will be able to do this well.

Tia: So this is really great that you're providing this information of how people can get involved because I know our listeners are going to want to know how to help. So we will put that link up with the podcast so that people can know where to go to find you to help you and your partner organizations.

Myron: Right, so the WNYC, our ECG, would be that the right link, not so much our individual organizations with regards to the Afghan evacuees, then whoever's managing that site can can put people in the right place so that they're most successful in helping us all do this job.

Tia: Wonderful. Thank you. I know, I know people will be really excited to help.

You've talked a lot about what your organization is doing and where you've come from and how your organization has grown in these twenty-five years. Where do you see your organization maybe five or 10 years from now?

Myron: What do you see Jericho Road doing? Well, you know, I've always been motivated by the need, so I think. That's going to continue to motivate us. It's not about competition or market share, It's about are there people who need excellent primary care who are falling through the cracks and how can we make a difference? Things are much different than they were 30 years ago. Twenty-five years ago when we started, there's other federally qualified community health centers. There's a number of like-minded organizations that are now filling in more of the gaps. So I think Jericho Road will look for opportunities where there is a need and try to fill those gaps I think will continue to grow on the east side and west side of Buffalo will continue to look for ways to address the social determinants of health, either on our own or in partnership with other like-minded organizations. I don't think we have to do it all. We can work together. We'll continue to grow our global work.

We need to get better with the work that we do at VVA in terms of where we'll probably be starting a capital campaign to get a better sort of space for that work. So we have you know, we have plenty, plenty of challenges ahead, plenty of ways that I think we can grow not because we have to grow, but because there's still a need. And so once all the patients are taken care of and everyone has good doctors, and then maybe we won't grow anymore. But for now, anywhere we open a site, we start a new doctor. Within two months, they're filled. So there still is an appetite for excellent primary health care in the Buffalo region.

Tia: Is there anything else you'd like to share with our listeners about the work that you're doing or ways that people can get involved to help address some of these issues?

Myron: Well, I mean, I think it would be a whole other topic, but there's so much to be said around the inequity that we see in terms of outcomes of care and what can be done. COVID has been a prime example of that. When you see we've done so much testing, testing probably thirty-five forty thousand people in the last 18 months.

And it's even though you test white folks, black folks, refugees, you see inequity and who tests positive, you see inequity and who gets sick, who gets to the hospital, who dies. And that's just COVID. So I think that definitely, the events of the last 18 months are pushing me to think more carefully about how we as an organization can more intentionally do our part to bridge those gaps.

Tia: Well, I can't thank you enough. And it's been such a pleasure to have you join us and to listen about the work that you're doing. We will be really interested to follow up and see how it goes with these Afghan evacuees.

Thank you to you and your organization and all your partners for the work that you're doing to address these inequities in health and health. And our School of Public Health and Health Professions is here to work with you if there are ways that we can support the work that you're doing. So thank you so much for taking the time today. We really appreciate it.

Myron: You're welcome. Thank you for the opportunity. I wish you well. Yes. Let's partner in the future if we can. Thank you.

Tia: All right, take care. It's been another episode of Buffalo HealthCast.

Tune in next time to hear more about health equity in Buffalo, the US and around the globe.

Hello and welcome to Buffalo Health Cast a podcast by students, faculty and staff of the university at Buffalo School of Public Health and Health Professions, we are your co-host, Tia Palermo, Jessica Kruger, Schuyler Lawson. And in this podcast, we cover topics related to health equity here in Buffalo, around the US and globally. And the first semester of the podcast, we're taking a deeper look at racism and health. We'll be talking to experts around the US as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population, health and well-being. You'll hear from practitioners, researchers, students and faculty from other universities who have made positive changes to improve health, equity and inclusion. 

Jessica: Hi, I'm Dr. Jessica Kruger. And today, my guests are Adam Graczyk and Sidney McFoy. Adam, tell us a little bit about you and your program.  

Adam: Hi, great to be here. I am a clinical assistant professor in the Department of Community Health and Health Behavior. And over the last couple of years, when I was still a student at the School of Public Health, health professionals had this week-long summer camp. It was basically high school students where students would come to campus and they would learn about public health, do a lot of hands-on experiences, take campus tours, that kind of thing. 

I sort of became more involved this pre the previous year. We decided we wanted to make it for credit. So, credit offered an experience, the appropriate credit this school was going to pay for the tuition and fees. And then it was sort of my job to make the content more rigorous. 

So instead of just sort of keep the fun part of it, but also put it in lectures about epidemiology of things. 

So, this program was really for underrepresented minority high school students from the Buffalo area, first generation college students. And it was really introduced them all to public health. 

I think maybe probably tell you this may have been one of her first or the first time she heard about what public health was and like how sort of broad it is. 

We hung out and Zoom two hours, twice a week. We had a lot of different discussions and a lot of different guest speakers. I tried to bring some improv principles into the class rooms. 

We would use different warm up activities, but I tried to bring in sort of the essence of improv, where it's an improv, there is no failure. And I really like that sort of comparison to the classroom, because in order to have good discussions and feel like everyone has input in a discussion, that has to be sort of like a safe space. And if you feel like you don't feel safe and you feel like failing is not an option, you're less likely to contribute to the discussion. 

Jessica: So this Pathways programs are Pathways Academy sounds like a really great opportunity for students to learn about public health while still feeling that they can learn more about being a student. 

So, Sydney, tell us about your experience and a little bit more about you in this program. 

Sydney: I want it to be a pediatric surgeon. So, when I heard about this program, I was like, OK, 

this would be a great opportunity for me to learn more about public health and public health and how it affects my community and how it helps my community and how I can play a part in public health. And so, when I took this course throughout the course, we had a bunch of different like people come in and teach us about like their specialties. 

So, we had epidemiology, we had physical therapy, we had occupational therapy. We had some nutritionist come in and teach us about that. I think my favorite was probably epidemiology and much of because of the situation that we're in right now. And I just didn't really know a lot about, you know, pandemics and epidemics before I experienced one for myself. 

And so, this program just gave me the opportunity to broaden my horizons and learn more about how I as an individual can contribute to public health and how it affects me and my community. 

Jessica: That's awesome to hear. I can't wait to see you become a pediatric surgeon. That's going to be an amazing goal to reach for your journey. But it sounds like some of these skills have really helped you and maybe even motivated you. 

Could you tell me more about that?  

Sydney: So, I'm a sophomore in high school, so I'm not sure what college I wanted to go to or even now I don't know what college I want to go to. But this program really helped me, you know, like stay focused in school. 

And it motivated me to they often talk about a lot of the people we saw. They talked about how important education is and how important, you know, like getting educated and going to school and having good grades and going to college. How important that is as far as, you know, individuals. And so, it helped me stay motivated in school and it helped me like it helped me want to learn. 

I came to class wanting to learn new things. So, we had this one lady come in and she was she did like admissions for four. U.B. Laura, Laura Connel is one. That's great. She's taught us all about what we need, like SAT scores and stuff and like what we need to get into B and what we need to do, even as like freshmen and sophomores, what we can do to further our education. 

Jessica: That's great to be able to know how to get to where you want to go. It's almost like a GPS on your way or a map that shows you to the Treasurer of Education. 

It sounds like you're well on your way out to tell us a little bit more about how you instill some of these skills into students and how you kind of built this curriculum to help ensure students are successful. 

Adam: We wanted to try to keep as many sorts of hands-on or different activities. We really wanted to have more group activity students, whether it was for a grade or not. 

It's sort of engagement there. But we really wanted to have opportunities for mentoring. 

So, we actually brought in all of the UB undergrad public health ambassadors. And we had this final project where each student would take your photo, a photo within their community that illustrate a public health problem. 

And then they would talk about that problem and what they could do with a degree in public health, how you could address that problem. And the ambassadors signed on every week and work with them sort of in groups of two or three. Yeah. I mean, like Sydney was saying to I wanted to have not just talk about public health topics and health professionals, professionals come in, but also, I'd like the college prep and what it was like being a student. They had a lot of opportunity to talk to the ambassadors, be like, what's it like on campus? 

What's it like being a student? And as much as I try, I'm getting further away from the age I was when I was an undergrad student. So, it's definitely more difficult for me to relate to that. But I think it was just.  me, it was a great experience because like. I was able to sort of instill passion, I guess, or get them to get them excited about it, and that's what I really like doing, just overall teacher. 

But they taught me a lot, too. And I really loved learning about their communities and what they would do to fix problems. And it was really we had so many great conversations.  

Jessica: Sydney, tell us about what your project was. I'm interested to know about these projects. 

Sydney: OK, so we had our final project and our goal, I guess, was to figure out a problem in our community that had to do with public health. And so, we had to take we had to take a picture of this problem and we had to write a report on it and then we had to present it. 

So, the topic that I chose was the disregard for COVID in the Black community. And the picture that I had was a picture of a mask and gloves, a picture of gloves, and it was just on the side of the road. And so, I took that as it represented what my topic was about. And I just wanted to bring awareness to the difficulties between the black community in the medical community, why people aren't taking it as seriously as they should. And then I wrote about how, like older people in the Black community that they have, they're more at risk to get sick or to die than people of other colors or white people. 

And Black people in general are more intergenerational. So, grandparents live with, you know, their kids and their grandkids. And so, if a six-year-old comes home and gets and is sick and they give it to their seven their 70-year-old grandfather, and then they get really sick, you know, then that's an issue. 

And so, I just talked about how they can become more aware of it and be safer. 

So, where mass social distance, follow CDC guidelines and then other things like taking the vaccine and a lot of reason that people don't take the vaccine is because they don't trust the medical professionals. 

And so, one thing that I said was a solution for that was that we could have vaccine stations be at like local churches and local community centers, places that people in the black community trust, people that they trust. 

Jessica: That was really profound finding. And that picture, I think, will stick with me forever. 

And the representation is, sadly, we see that around more and more often. 

But I think your solution to this problem is also quite innovative and something that we have started to see happen as we see people who are hesitant for their second vaccine. 

So, you're wise beyond your years. This is great. Maybe you should come over to public help instead of going to that pediatric raveled. I'm sure Adam has tried to convert you too. 

Adam, you want to tell us a little bit more about your main goal with this final project and how that this final project has maybe help students to really synthesize what it is to be a public health professional? 

Adam: Right. So, I think I mean, it's pretty powerful. Obviously, you could describe we've described the photo, but the way we'll see it, it's pretty powerful. What just a single photo can illustrate. And the ways that you describe the problem and how you solve the problem that all stems from is the single photo. 

But I think the most important thing is that she made a personal connection. It's in her neighborhood. And I think when you're able to do that, make it have a personal connection or make it more personal, you're really able to sort of embrace new ideas, new concepts in a different way than you would use just hearing about it in a lecture hall or something. 

I think it's so important that we really have some of these immersive experiences for our students and get them to see the problems around them, because I'm sure, Sydney, as you were doing this, this was not the only problem that you saw within your community, but it begins to help you think about other challenges that your community might be facing. 

Jessica: So, I have to ask Sydney, what was your favorite part about this program? 

Sydney: I would definitely say the whole like getting to meet new people. And when we have discussions, I love having discussions. I love just like open discussion. And everyone's just throwing in their two cents. I love those. So just getting to meet new people, hearing no opinions, you know, like hearing new ideas and just, you know, open discussion with new people. It was great. That was probably my favorite aspect of it. That's awesome. 

Jessica: And I, I bet it gives you a little bit of a different perspective about what college is. I myself am a first-generation student and I wish there was a program like this for me because I had no clue what college would be like. 

Did you feel like this made you a little bit more comfortable thinking about colleges and being part of a university life in the future? 

Sydney: Definitely. The ambassadors, my ambassadors, she was you know, she goes to UB and she just was so open about her college experience and so I could just ask questions and she would tell me about like classes and living in a dorm, having a roommate, being away from home. Just all of those things, things that I was nervous about. 

She just explained it to me and, you know, kind of helped me kind of help ease my nerves about college. So, yes, I definitely feel like it has. Help me feel more confident about going to college. 

Jessica: Fantastic. What was your favorite part?  

Adam: It was really I would also say the discussions. 

I was I was excited that I was able to do some of the teaching techniques that I do with the undergrad level. And I just I, I hadn't taught high school kids before. And it's not like, oh, well, I'll try to do similar things that what I do and at work. And I do feel like there was just such a lot of the students there to sort of embrace the material. And they asked lots of questions and it was great. They weren't shy to ask questions. I just think it was it was very rewarding. 

Jessica: Yeah, most definitely, especially when you make those connections with students and can see that light bulb moment, I know this is faculty really live for that. And I'm sure you had a lot of those in this class. 

Adam: Yeah. And we've got a lot of qualitative feedback. I do have a few numbers that I could share. How successful pathway's academy. So, to be at the beginning of the academy. 

At the end, we gave a 15-question public health knowledge quiz, and it just basically asked different questions about public health. 

And they were all sorts of topics that we were going to cover throughout the seven-week period at the beginning of the academy. The average was an eight out of 15. And at the end, the average was a 12 and 15. So we definitely saw improvement there. 

We also looked at self-efficacy, their confidence in their ability to succeed in a public health or health profession. We saw almost a 10-point increase from the beginning of the academy to the end. Also saw a positive increase in public health attitudes, positive attitudes to public health, and we did see an increase in intentions to pursue a career in public health professions by the end. So just really, really good stuff there.  

Jessica: Sounds like an amazing success in Sydney. Kind of highlighted some of those findings as we've been talking to her around her confidence and even knowledge about public health. 

Now the nation knows what we do, the pre-pandemic, many people didn't. And so, I'm glad more students are interested in learning about this profession. 

I like to wrap up with every episode with what's next. So, tell us what's next for you, Sydney, on your journey to your next step in education. What are you looking forward to? 

Sydney: I will be starting. I'm almost done with my sophomore year, so I'll be going into junior year in a couple of months. I've signed up for numerous AP classes, so I'm excited for that. I signed up for was AP psychology. 

And I'm very excited because I love learning about like humans and what makes humans humans and why they do what they do. So, I'm very excited for that class.  

Jessica: Yeah, that's awesome. And that health, behavior and psychology are very closely related. So, I'm sure you're going to be able to bring some of that information that you learned into your next semester. 

That's awesome. Adam, how about you?  

Adam: I'm going to Disney World. No, I'm just kidding. I look forward to sort of growing this program. And year after year, we're going to have like this really large group of people. And I'd love to just have, like, summer. Events or something like a cookout or other events on campus and just sort of continue to follow up with all with all the students, see where they're at and what they're doing, I think it's really cool. Sounds like you made some lifelong connections here with students. 

And I'm sure you'll watch them all be very successful to. 

Jessica: Thank you very much. Today's guest worker, Adam Graczyk and Sydney McFoy, thank you very much. 

This has been another episode of Buffalo Health Cast. Tune in next time to hear more about health equity in Buffalo, the US and around the globe. 

Hello and welcome to Buffalo HealthCast a podcast by students, faculty and staff of the University at Buffalo School of Public Health and Health Professions, we’re your co-hosts, Tia Palermo, Jessica Kruger and Schuyler Lawson.

And in this podcast, we cover topics related to health equity here in Buffalo, around the US and globally. And this first semester, the podcast, we're taking a deeper look at racism and health.

We'll be talking to experts around the US as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population, health, and well-being. You'll hear from practitioners, researchers, students, and faculty from other universities who have made positive changes to improve health, equity and inclusion.

Schuyler Lawson: Hello, everyone, and welcome to another episode of Buffalo HealthCast University, Buffalo's premier public health podcast. I'm your host, Schuyler Lawson. I'm a first year PhD candidate in the Department of Community Health and Health Program.

With us today is Alexander J Wright, the founder and president of the African Heritage Food Co-op. Thank you for taking the time to the interview today. Thank you. Let's go. We'll be glad to have you. And first off, can you tell us a little bit about yourself?

Alexander Wright: Yeah, I was born in Buffalo, left when I was three, came back at 12 and went away to college at 18, came back at 20, and I've been here ever since, I have a bachelor's of science business management and I have a law degree from University of Buffalo's John Law O'Brien School of Law. I've always been community-focused.

Schuyler Lawson: That's what I've heard about. People always end up coming back to Buffalo in your story kind of ties into that. I've heard that quite a bit. People leave and they end up coming back. So, yeah, my next question is, so what is the mission of the African Heritage Food Co-op?

Alexander Wright: The mission of the African Heritage Food Co-op is to eliminate food deserts and combat unemployment and price gouging, the inner city in particular.

Schuyler Lawson: And it's a that's a pretty noble mission. And that kind of leads into my next question. I'm glad you mentioned your you be your juris degree from now. UB school of law, correct? Yep. So how did that inform how does that inform the creation and the management of the American Heritage of Food Co-op that that type of education background?

Alexander Wright: I think see, law school teaches you one thing for three years for research.

Right. And critical thinking. So, I think one of the things that helped me to be successful is when I have the ability to read my own contracts, I have the ability to create and negotiate and a lot of ways that I learned it to be. But also, it increased my networking ability.

So, because I'm able to see both sides of anything, that's one thing they force you to do your first year, your third year. They make you argue size that you're four in size this year gets to enable you to be able to understand, you know. So, it allowed me to relate to folks I work with a lot of people who politically don't think like me. And I work with a lot of people who don't look like me.

But I have a skill set to where I can deal with everyone on a spectrum, whether you're, you know, if you support Trump, whether you are no matter who you are, I can sit down and have a conversation with you and find common ground.

And that's one thing I had to do, working out with local farmers. And as I'm driving out and I'm seeing Confederate flags, I'm seeing Trump support, I'm seeing, you know, don't tread on me.

And a lot of ultra-nationalism, which a lot of times translates into overt racism for people of African descent. But we've been able to get through a lot of that stuff and be successful.

Schuyler Lawson: It's pretty interesting. How did that level of background translate into kind of a major sort of a diplomat in ways you're able to sort of reach out to people in ways that others would probably find unacceptable or very difficult? You're able to can you be able to reach a common ground by understanding that the point of view of the other and then it leads to partnership with someone that you're you may be diametrically opposed to as far as belief systems, whether it be political worldviews. 

Alexander Wright: One of the things is there's the person and then there's the idea. And a lot of times we merged the two because you have this ideal, you're this kind of person. And in a lot of times that isn't the case. I mean, sometimes it is what a lot of times that in the case, some people have ideas because they're ignorant to other ideas that are there. Some people have belief systems because they were just taught that they didn't do any research.

So, you know, I always start off with this is a decent person, until they cheat, they show me otherwise and then we just go from there.

Schuyler Lawson: Well, so far, this leads into my next question. Actually, I'm wondering, what are some projects that the African Heritage Food Co-op has recently undertaken? One of the biggest things is just fighting hunger and COVID we fed or about one hundred thousand families in 2020 who were really affected by losing jobs.

Or, you know, they say when America gets a cold, you know, poor folks get the flu. So COVID has been difficult on a lot of people, but even more difficult on the people who are with you had it difficult.

So, we're able to partner with organizations and projects like the Buffalo Health Equity Network, the Independent Foundation and a health foundation to Western New York excuse me, and many others. And we were able to get healthy food out to folks that didn't have it, so that's been a major focus of what we've been doing while building up our Niagara Falls store and renovating and putting together our Buffalo Carlton Street store as well.

So, it's been a very, very busy time for us. And we're looking forward to continuing to work because, you know, we receive fanfare and some notoriety, but none of that means anything if we don't really have a functioning grocery stores in areas that have been victim of food apartheid.

Schuyler Lawson: So, I'm just going to go into a little bit more detail about the Buffalo branch that's being built for the African Heritage Co-op. I know there’s one in Niagara Falls.

Alexander Wright: So, in Buffalo, we acquired through a generous donation a historically a locally historically landmark building at 238 Carlton Street. It's an air of the fruit, though some like to refer to that area as a medical campus.

But it's the truth, though. It was a fruit built before it was a medical campus through the medical campus resides in the food. And the reason I'm so specific with language there is it's like saying Columbus discovered America, you know, and people were already here right before medical campus.

What was it? You know, where people there was just this barren place that nobody, nobody was in?

No. There are people there with a long, proud history.

Right. So, I like to say that because that narrative is part of the institutional racism that that plagues our city. We received fifty thousand to restore it from the Buffalo Niagara Preservation Network. We were able to pay back some of that, which is good. We’re working with architects now. We have our external drawings. We're working on our internal drawings. Once we have internal drawings, we can start our official fundraising. Our fundraising was pushed back because of like a lot of ways you can work fundraisers is by having people come see the building, getting an understanding of what's going on, you know, and then they support one that, you know, 20, 30, 50 hundred people in the building. So that's why we wanted to wait until we had our interior designs so that we now people will be able to virtually walk through and actually see everything that's going to be there.

Schuyler Lawson: And this is this is a very ambitious project. And I think it's going to be a good location that would really benefit from that type of the type of resource you have to have a sort of an approximation of when it'll be completed or did the pandemic kind of throw things into sort of more uncertainty?

Alexander Wright: Yeah, the pandemic threw everything into, you know, we wanted 2021 what built and then go in this year. But obviously that's been pushed back. We're waiting on these internal drawings, hopefully what have them. I wanted to launch a fundraiser during Black History Month but is symbolic. It doesn't look like that's going to happen. The drawings are being perfected and approved. So once we do that, then we'll be ready to rock and roll.

But maybe we can do it in April, which people don't know. Black History Month started as a week in April. And then from there, February was chosen because of the birthdays that fall within February.

And it's a big I'm a big, big fan of Carter G Woodson and what he was able to do.

Schuyler Lawson: If I recall correctly, he's a black historian, correct?

Alexander Wright: Yes. 

Schuyler Lawson: I'm glad you mentioned the pandemic. That kind of ties to another question that I had. And how is the COVID-19 pandemic impacted the way that you that you all run by African heritage. How was it had to evolve and what have you had to change to keep on providing those very essential services?

Alexander Wright: So, we've revamped our website so people can now order online pretty quickly. They can also call in their orders. We're not taking people in the stores right now because of COVID doing free delivery. So, the only thing you have to pay for is actually your items. And we deliver right to your house.

Of course, we take all of our precautions. We have visors and masks and things like that.

We are essential workers. You know, when you work in grocery work, getting food, you're essential. And one of the things that we do differently for elders, you know, we come to the door, and we see an elder there. We will bring it inside if you know, if that person wants that to happen and we'll put it on their counter for them, so they don't have to then try to pick it up. And everything we try to do with care and with a purpose, a community for.

Schuyler Lawson: And can you tell us a bit about what type of type of products you offer on your deliveries?

Alexander Wright: Yeah, and we can basically source anything. It just is a matter of how long it takes. So how specific you are, on basic peppers, onions, potatoes, things like that that's 24 hours. It's not a problem.

We're not at the door dash, Instacart level where you go in and you get it in two hours, but you have it the next day. And that's for 90 percent of items. If you want, you know, organic, I don't know wolfbane or something, you know, something like exotic why would consider exotic, but I understand for some people that's not so I'm not saying that it's exotic. I'm just saying for me it is. That may take a couple of days, you know, we've got a relatively quick turnaround and everything and delivered right to your house and this is what we've been doing because our not the force store, if it's huge and you just can't I can't risk the safety of our employees and I can't risk the safety of the community being bunched up in here buying stuff or, you know, because when you're looking at producer, you know, if not, it's not a bang, bang, bang thing. People come in, they want to pick stuff up, feel it or have a conversation about it. Like it's just a real communal body produces a communal thing and it's just unsafe right now with the size of our store to have people walking in.

Schuyler Lawson: Yeah, that's definitely understandable. But it seems like you've still been able to make some great accomplishments in spite of the limitations that have been imposed by the pandemic. But I have another question. We're talking about, you know, making accomplishments. What would you say is the has been the greatest accomplishment of the African Heritage Food Co-op.

Alexander Wright: The greatest accomplishment of the African Heritage Food Co-op has been a couple of things that I see.

One hope I see other co-ops forming. I see other people selling produce that weren’t selling produce before in areas that they were going into before. So that's very exciting to me. I don't see that as competition. I see that as there are, you know, three hundred thousand people who need fresh fruits and vegetables. I would love to service them all. I don't have the capacity to do it.

So, if you jump in with your food cart and you're making it happen and I think the black business bazaars that we've been able to institute now, we've gone away from those, you know, in the pandemic and in our sights. But I've seen people pick it up and do something like it, actually, a lot of people. So I'm very excited about that to feel a little bit like a trendsetter. You know, the beautiful thing about the black, this is bazaar as it was.

It was giving small businesses and tabletop folks an opportunity to come out and get exposure, new customers and put a focus on economics. So, I was very excited when I saw the city of Buffalo to Buffalo to a Black business week, which to my knowledge was not happening before us and before we were pushing the envelope on Black business bazaars. So, I'm really excited about people who are grabbing on and making that happen. And I think that's one of the biggest accomplishments to me, seeing folks catch on to the idea and putting their own spin on it and making it even, you know, even greater.

Schuyler Lawson: You can take pride in, you know, being the one that got the ball rolling, right? Yeah, it's like a kind of a pioneer in that respect.

OK, so I have another question for you. Can you talk more about your collaboration with the Lexington Co-op? That's a call that I'm sure many of our listeners know about. 

Alexander Wright: Yeah, yeah. Yeah. Well, there's a principle In cooperative's, where you have to help other cooperative's being like, you just have to they have held true to that even from our beginning, as far as they helped us immensely with our lawyer to incorporate. You know, they helped us with half of our consulting fee. We brought consultants in.

And I reached out to the general manager to allow a bunch when I have questions or I'm frustrated and I just want to flip the table over, you know, but not just [inaudible] co-op. Like we've reached out to [inaudible] in Pittsburgh.

We've reached out to. Co-ops in Oakland, California, visited co-ops out there. That's one of the things we did. We really did research and talk to a lot of folks, you know, and anybody who's like listening to this and starting something really, really do your research and talk to people about what? About what you want to do. 

Schuyler Lawson: Yeah, yeah. I didn't know about that after the principle of co-ops had to help each other. And that's really you know for sure.

Alexander Wright: And even just not just liked and didn't like the bread hive, which is toll on the grow operative, which is a co-op. You know, they have all done something to help us and other co-ops nationally. You know, somebody out there like I'll see a three hundred people donation some time from this co-op, most recently the Lexington they did for December.

I guess you can round up your purchases and raise money for an organization. They raised $10,000 for us. And what's beautiful about that money is. We were doing work with the county in the Buffalo Equity Network that covered until December.

So, we're waiting to hear. If we're going to be refunded, well, we're just a vendor in it again, and then hopefully they're funded again and they continue to use us as a vendor. But while we awaiting this, ten thousand is allowed us to keep going on in January, you know, so people didn't miss a beat while we're waiting on you hear from this funding and some other stuff, you know, to help those folks that just can't help themselves right now, OK?

Schuyler Lawson: So essentially, it's like a stopgap type of money.

Alexander Wright: Yeah, yeah. And I mean, they didn't know what to do before. We didn't know what it would before it got here. It just came right on time and allowed us to continue operations and feeding. We feed. 200-500 families, you know, and that doesn't include like our direct orders.

That's just the community stuff. And suppose that's a very generous offering.

Schuyler Lawson: I imagine it sounds more beneficial to many of the people that depend on your services.

Alexander Wright: We pull up and people are like, oh, the full people, what's going on?

Lady gave me a limbe, which is nice. If people don't know what I they are. That's flavor ice. And it's usually like for Puerto Rican and Hispanic, Latin American. Right, so we got the I got there were some photos, and the lady was like, “oh, let me I got to give you something if you like.

What's the flavor you like?” I love that you really connect with folks throughout your community.

And I think that's one of the biggest things for me. When I just walk to the hood and people are like, Hey, Alex, man, you know, we appreciate what you do, and, you know, that's it, that's worth more to me than any award, you know, and being fiscally responsible, you know, for employees who are around the community like that. It's exciting to me to be able to do that. Yeah, that's, you know, it's there's only one.

Schuyler Lawson: Yeah. OK, so I got another question for you. This one's kind of broad, so I'm not, in your opinion, what are the biggest drivers of health disparities and what would it take to eliminate these?

Alexander Wright: First thing. Give the funding to the people in the community. I think one of the biggest mistakes that we continue to make is we'll give a million dollars to whatever.

OK, now they'll take that million dollars and they need a salary, somebody else's salary, somebody else needs a salary, somebody else's salary. So, you mess around, you have 10 salaries out of those 10 salaries. They have one person who may represent the community and be your community liaison.

Right? Well, what happens is. That black face that they find, is rarely actually connected to the community. Right, and they just assume that because this person is black, that this person is going to connect with the community. You know, that just happened in Washington was black and that's kind of black person. A lot of times these companies, these organizations want to bring to my neighborhood and then they don't think like me. They don't have my same experience. They don't understand what's what. And then there's a disconnect. If people like, well, we hired a community liaison who we are a diversity coordinator, and they in the community and the community just doesn't want to work with them because we have this guy where you come from.

Why are you my face? What should happen is, all right, here's a problem that's affecting the community. Is there anyone in the community already working on this problem? So, we're going to put funds into capacity building and helping that institution, that organization or those people build out the word continue out the work.

Right. And not just on, here's a grant that's heavily restricted. Right. Here's a grant that's not heavily restricted. You're also a CPA who is also an accountant. Right. Because the other thing that people don't help you with, you know, here's a grant, but you know what I'm saying?

Schuyler Lawson: They don't need know how to manage it. Right, in these things that you need.

Alexander Wright: Right. So, you have a lot of people who are doing good work, who aren't getting funding coming out of their pocket or they get a little bit of funding? Right. But then they're trying to figure out, OK, what's the paperwork? How can I write?

So what happens if people, again, with the education, with connections, with the application for protection and they get this lump sum of funds and they use it how they see fit? A lot of times on salary, a lot of times on just things that are going to, you know, make me look not racist because I'm going to shake hands and pretend like everything is good. Right. And our institutions do this our foundations do this a lot.

And it's one thing we do. You want to solve the problem, don't you? That's really what it feels like. You know, we spend or they'll give people give a hundred thousand dollars to do a feasibility study or here's is a hundred thousand dollars to go and do surveys in the community.

And now you're paying all the students 15 bucks an hour to go out there and knock on doors.

You're paying people to do whatever. Right. So now the money's gone and you have this data, which is great, you know, for people who are becoming PhDs, which is before schools and papers and articles and that kind of stuff. Right. So now you have this beautiful article, well written. Awesome.

Who's going to be read by academics who are going to study it, have a think tank about it, get some more funding to look at it, write a book about it. And all this time, people are dying, people are starving, people are right. So we just wasted billions of dollars on an academic boondoggle.

That's problematic, is problematic. So how we how do we change it? We start being smart who's doing it? Or if no one is doing it, who can do it? There's this documentary called Solar Mamas, Women who were from the Middle East and North Africa who were illiterate. It took them to London for six months, taught them solar power to bring back to their villages. Right. They became solar engineers, people who were illiterate. Abusing those cultures in silence in those cultures and those women became engineers, so you can't tell me if you can do that.

You can't take Leroy in the Keysha who made it to high school. Right. Teach them give them an opportunity to do the same thing. Right. They can bag up produce, they can weigh produce, they can deliver produce, right. We don't need an organization to come from somewhere else into our neighborhood to do that. Put the money into the people who are already there, allow them to build themselves up. That's how you change the community and that's how in the health. Is it just. My body, if it's connected to me economically, so now, OK, he should keep his job, my daughter Keysha’s job is to do fruits and vegetables.

OK, I know that she gets paid. I'm a go ahead and get some right here because we're going to do the same things. Other people actually do the same thing. Oh, man. All right. Well, support. We got to support our own line to go, OK.

So that's one now you get grandma to throw some of those things in the pot. Whip it up right now. Oh, man, this is good, Grandma. This is what is this kale? What is what is this?

So, then you have the economic portion that you have the portion of somebody cooking it, making it taste good. Right. And you start with the fruits and vegetables that people are already eating. What happens is, is we roll up with the acorn squash boom, acorn squash or like what the what?

I don't. I don't. What is this? I don't cook with this. Right. But if you're a culturally relevant culturally, if you understood, you might. OK, what can you do? The sweet potato? What can you do with a regular white potato which everybody eats. Right. What can you do with a green pepper, which everybody how does onion. Everybody like those onions. So, there's things that everyone does, the things that are more culturally relevant. So, figure that out, which isn't hard. Call me. I'll tell you right for me, call Alice, call Rita Hubbard. Robinson, call. There are people who are doing this food work. 

Right, right. So, I don't want to come off as frustrated because I'm not necessarily, well, a little frustrated. But I just see, it's like if you see the solution, right, I really feel like I have the solution. You work with the people who are here, but because those are the people that are going to stay.

Right. That's the same thing with the solar mom thing.

Schuyler Lawson: The reason for the true stakeholder's right, the reason they dealt with women, because women stay in the village, raise their family, they're going to be here. Right. So that's what the same thing you do, these folks that are here, because we're the only folks that can do it with any longevity.

What happens is you have a great executive director of a great foundation, right? And until that person runs for senator or until that person wants a family or until that person, whatever that person does, everything seems good.

But because it's not in the next person who doesn't see the community focus or what happens is there are hot items. So, one year is full justice. Next year, it's human trafficking. Next year, you know, it's STEM programs, right. So, what's hot and what's funded, you know, that goes around, but it doesn't go.

OK. Oh, we fix food insecurity. So now let's move on, nothing gets fixed. Nothing gets fixed.

Nothing. That's the problem, man, like we throw money at this thing, we take pictures, we write journals, and then we blow away as if people who were struggling aren't still struggling.

Schuyler Lawson: Yes, so I see this all essentially a lack of continuity.

Alexander Wright: Lack of continuity and a lack of proper placement of funds. You know, and when they do give someone who is in the club some funding, it comes with zip ties, handcuffs, ropes, oh, you know, oh, well, if you spend $10,000, then we'll give you $10,000.

If I had $10,000 to spend. Why would I be here? Anyway, next question, I think I've been on this, I've harped on this one a while.

Schuyler Lawson: So, this response, the kind of I mean, it's not something that can be necessarily summed up in just a few sentences, and I think that sort of passion to try to encapsulate it all, the kind of the continued failures of institutions to address the issue properly.

We thank you for your response. So, I'm hoping that at least to my last question. Is there anything else that you would like to share with our listeners? Anything.

Alexander Wright: Yeah. There are a lot of things you can do to help. But always help in dignity. People that you want to help are not children, they don't need you to change them and wipe their bottoms and come to them with a with a condescending tone or attitude. This also doesn't mean that you have to walk on eggshells. Be real, be authentic, be upfront with your ignorance, because you have some, I promise you, and be willing to learn from the people you're trying to work with as you're trying to impart whatever you're trying to impart.

Schuyler Lawson: Wise words.

Alexander Wright: So that's it. OK.

Schuyler Lawson: Thank you. Thank you for that reply and thanks again for taking the time to be on our podcast. We want to we hope to have you on again to discuss your future projects.

And is there any way, is there where our listeners can learn more about the African heritage food co-op?

Alexander Wright: Definitely can. You can check this out at myahfc.com.

Check us out on Facebook, African Heritage Food Co-op. We're the only one. 

And the new initiative for Legacy Farms, where we're leasing out plots of farmland for community folks to come out and grow in. The co-op is going to purchase the stuff that they grow to do an economic infusion into those homes. And you can find out about that. Legacy farms, that or legacy farms on Facebook.

Schuyler Lawson: Again, the only one thank you for sharing that has been another episode of Buffalo HealthCast. Tune in next time to hear more about health equity in Buffalo, the US and around the globe.

Tia Palermo: Welcome to the Buffalo HealthCast, I'm Tim Palermo, one of your co-hosts. And I'm very excited to be here today with Dr. Terri Watson. Dr. Watson is associate professor of educational leadership in the Department of Leadership and Human Develop at the City College of New York. This year she is also a Center for Diversity Innovation Distinguished visiting scholar at the University at Buffalo. She holds a PhD and educational leadership, and her current research agenda examines parent engagement in urban schools and communities. Her aim as a scholar activist is to improve the educational outcomes and life chances of historically excluded and underserved children and families. I'm really excited to have her on our podcast today. Welcome, Terri. 

Terri Watson: Thank you very much. Thank you for having me. I'm looking forward to this conversation. And I'm excited to be here.  

Tia Palermo: So, as you know, this podcast is broadly focused on racism and health. And I invited you here because of your work with historically excluded and underserved children. 

Can you tell us a little bit about this work and what brings you to this work? 

Terri Watson: Well, thank you. So, a big part of the work, I guess, for us as scholars is who we are. And as a black woman born and raised in Harlem, which is a historically black enclave in New York City. My work is for and about, you know, people of color in general and black people more specifically. And my I guess my reason for being here is to bring our realities to the table. 

I think oftentimes what happens in communities of color go unaddressed because the people advocating on our behalf do not live in their respective community. 

And so, you know, coming from Harlem, living in Harlem, working in Harlem, I think it's important that I represent this particular reality, you know, in the K through 12 pipeline, our institutions, if you will. So that's why I'm here, to see what we can do better and more meaningfully and thoughtfully to improve the realities of all children. 

But I'm most concerned with children and people of color because historically our needs have gone unmet. 

Tia Palermo: That's great. Thank you. So, when you work with these communities, can you tell us a little bit about what you see in how racism and health interact in the families and communities that you work with? And how does this affect their education and their opportunities in life? 

Terri Watson: Well, I guess, you know, bring it back to the personal. So, although I was born in Harlem Hospital and raised in Harlem, I spent my early years in the South Bronx. So, the zip code is a one zero four five four. That is the poorest congressional district in the United States. 

And unfortunately, the asthma rates are particularly high. Gun violence premature were many of the realities that this particular community faces and others like it faces that there are health disparities that simply go unmet or unchallenged because families do not have access to health care. 

And oftentimes, when you do go to the doctor, per say, let's say, you know, it's the emergency room instead of going in for, you know, annual checkups and physicals. So, the bills that are encumbered on behalf of health care usually can go bankrupt and already challenged, financially challenged family and or community and like education. 

You know, many of the opportunity gaps present in education are systemic, meaning the problems are deeply rooted in the system in itself. So, there's nothing wrong with the people per say. It's the systems that we are forced to function in. That does not prioritize the health and the educational needs of our children. And so the unfortunate connect between education and health care is that in both instances, you know, communities of color have little to no to no access to no meaningful educational outcomes or needed medical attention, be it, you know, mental health, the dentist, you know, general health care like those things are lacking in communities of color across the nation, not just in the South Bronx or Harlem, but, you know, there's a Harlem and South Bronx and every state across the landscape. 

Tia Palermo: Yeah. You talked about access to health care and you've talked about educational opportunities. And in 2020, we've really just seen these inequities exacerbated with parents struggling to help their children through school at home. And also, we're seeing disparities in infection rates and access to treatment. Are you seeing any of this with the communities that work you work with? And how is this playing out? 

Terri Watson: Oh, yeah, I'm definitely seeing it. And in many ways experiencing it. As you know, I'm Covid-19 disproportionately affects, you know, communities of color, you know, black folks in particular. And even now in New York City. And we're in just earlier this week, many schools that were were shuttered due to Covid-19 baby open. And this is interesting, despite the fact that New York's public schools. 

Over one million children are primarily black around. What we found earlier this week is that 12000 more white schools returned, I'm sorry, 12000 more white students returned to previously shuttered schools than black children. 

And while, you know, remote learning was considered and is considered less than ideal for all children, many communities of color are afraid to send their children back to school for fear that not only will they get Covid-19, but let's say if they don't and they will bring it home. And as you know, in urban communities, many of our households are intergenerational. 

So even if the child said she alive, you're going to infect your grandmother, your uncle, or even an older family member. So, you know, the way this pandemic has impacted education will be felt for years to come. But on the bright side, what I'm hoping to come out of it and learn from this is that even in this pandemic, communities of color have always come together because this isn't the first time this has happened. 

You know, if you look at our nation's history and, you know, like 1863, 1964, those were all pivotal years in our nation's history. So, what I'm hoping is that in this pandemic in 2020, not only is it, you know, the Covid-19, but there's an attack on democracy. 

And, you know, the Black Lives Matter movement is now global. I'm hoping that we come together as a nation and as a people and find some real grass roots ways to address the inequities, not just in equity, not just in education, but to address the inequities in health care. 

So even now that the vaccine will soon be distributed in the United States, you know, who will have access to, you know, who's on the first line? And in many communities of color are afraid to take the vaccine. Right. So, if you think, back to the Tuskegee experiment. If you think about the side effects and the long-term impact of this vaccine that was newly developed, so many, many communities of color are hesitant to take the vaccine. Rightly so. So, I know health care providers are really trying to go out and push for people to take it in. I will. And I hope that as a people and community, we do. 

But I can understand one's hesitance. And we have to find, you know, better ways to not only inform, but to do our due diligence, making sure that we are not selling communities of color, a bill of sale that we can't uphold. If those two doses. So, if you give the first dose. Make sure you give the second dose. And then how do we follow up for the long-term impact of this vaccine? 

And will they give the same care to communities of color that they give to, you know, other stakeholders in this, which is, you know, by large, no white middle class America. 

So, will we get the same, you know, options and priorities in this drug, in treatment, in battling not just Covid-19, but other issues that are prevalent in our community? There's so much to unpack there. Yeah. You talked about the racial disparities in the reopenings of schools in New York City and here in Buffalo. 

I have to say that we're seeing the same thing. So, the Buffalo City schools, which are predominantly black and brown, have not gone back to school in person at all, while the suburbs, which are whiter and less diverse, although some of the suburbs are diverse, but much less so than the Buffalo City schools, and they have all to some extent return to hybrid or in person learning. So here in Buffalo, we see a very stark difference in the reopening of schools, which, as you have said, is going to have long term input packs for the foreseeable future. 

Tia Palermo: And you also talked about a lot of these disparities in access to health care and how these structural factors really influence. So, it's not necessarily always decisions and behaviors at the individual level. Only people are being influenced by these much larger influences in their lives that we don't always recognize and name. So here in Buffalo, we have a long history of redlining, which has contributed to scarcity of resources in certain communities. 

We have health disparities where we see differences in life expectancy based on which side of Main Street you live on. And there's a lot of factors at the structural level that have led to some of these disparities. And just in normal times, we see how these contribute to differences in health outcomes and access to services for help. And it's going to be really interesting to see how it plays out with the access to the vaccines. 

And also, as you mentioned, the follow up for care and the two doses, interestingly enough, here in Erie County, of which Buffalo is a part we don't actually see disparities by race, ethnicity in mortality took at 19 like has, which has been seen in other areas of the country. 

So that is kind of interesting and maybe speaks to the work that a lot of community organizations and Department of Health. I've been doing to ensure access to services for our various communities. So, I want to turn a little bit to some of these larger structural issues that factors that you've been talking about, which influence these outcomes at the edge in terms of education, in terms of health. 

So, you were recently on a podcast with Sheldon Eakins. And it was entitled Being Kind Is Not the Same as Being Anti-racist. And thus was a leading equity podcast. You were talking about the media and the importance of seeing children, seeing people who reflect them, who look at them. So here at the State University of New York or SUNY, we are the largest comprehensive university system in the United States. 

We encompass 64 institutions. And according to our University Systems Prodigy Web site, there is a pronounced gap between the racial and ethnic diversity of SUNY faculty members, where the nine percent are underrepresented minority, whereas in our student body, almost one in three underrepresented minorities. So, can you talk a little bit how this what you were talking about in terms of children and schools? How is this important in a university setting? And why is diversity of faculty important? 

Terri Watson: Right. Well, diversity of faculty is really important because. You can't be what you can't see. You know, much of the work we do as a person of color, I can say is just simply showing up like in many spaces. My presence itself is liberating. Not only does it say, you know, there's diversity and inclusion literally, you know, in place. But more importantly and hopefully a diversity of ideas. And in terms of potential for young people, what you can be and see. 

And so, what I found that I shared I just left the faculty meeting, you know, over 100 faculty members in the school of Education. And as I look across, kind of, you know, the panels, the lack of diversity was palpable. And when I thought about, you know, these white voids, I thought about I hope the scholarship does not mirror this meaning. Are we considering the realities of people who look different than us? 

I know as a as a black woman, it's important that I put, you know, the realities and experiences of black folk, you know, in the forefront of my work and scholarship. And I wondered, you know, how often is that lost in these spaces and not just for black folks, but for diverse people? 

You know, it's important that people of color are represented because as the nation browns, there will be a need to increase access and make sure that schools become equitable spaces. And I think what happens in higher ed, because, you know, in many ways we inform the next generation of scholars by sharing our ideas and perspectives.  

And if they are not diverse, then we are simply repeating systemic inequities. And so, it's important that institutions, particularly one as big, big as SUNY, that we are intentional in diversifying, you know, who are students. See, because oftentimes there's a cultural disconnect, in fact, between the professor and the student. And so various realities and experiences do not go unpacked or dressed. 

And students often feel, you know, alone or ignored. And you think about attrition rates, you know, who stays and who becomes successful and more importantly, who return back to the academy. As a professor, no, we won't see diverse people if we don't nurture diverse minds and talents and thoughts that are contrary to our own. 

And the I guess the downside of this is that oftentimes institutions as big as Buffalo, you know, we function in silos, meaning we don't talk across the board. What happens in education doesn't make it over to the school of medicine or to the law school or even to psychology. 

So, it's important that we come together and realize that the problem we have while it's in our institution, but it's also inherent in America. So how can we begin as a place of learning to write these long-held injustices like what can we do as people concerned with the next generations, not just generation, but generations of scholars? And how can we make sure that we are encouraging and nurturing and respecting diversity if we don't hire faculty members who look like our student body and if we don't nurture those diverse members of our student body, if we keep relying on the canon and, you know, like what a professor should look like, you know, an older white man in a cardigan sweater. 

That's not what I see that that would never sustain or nurture me. So how do we make sure that we are meeting the needs of our students? You know, in a real and meaningful way. 

And part of that is simply listening to them and having faculty that looks like them, that comes from those communities and neighborhoods. And because New York is so diverse, you know, how is that being lost in Buffalo? 

What are we doing to encourage diverse people to want to come to Buffalo to do their work? Because Buffalo looks a lot like New York City and in these inequities will not, you know, write themselves if we don't take specific and targeted actions to increase the pipeline. 

So, I'm hopeful that Buffalo remains the least a leader and is and really, you know, looks at those numbers from that website and ask, what can we do better? What have we done? What haven't we tried? Because the talent is out there. 

But we have to have the moral and political will to make the change that we know we need. Absolutely. And speaking of making those changes, you often talk about deconstructing and reconstructing. So, can you talk a little bit about what you mean by those generally? And what would this look like here at Buffalo or here at SUNY? 

I think in terms of deconstructing, looking at policies and practices that. In many ways, we're marrying theory to practice, like, you know, is one thing to espouse something. But how do you put it in action? And by doing that, we have to kind of reflect on what we do, like really take apart what we do and understand the rationale behind it and then say if we want change, well, we have to kind of you know, people talk about the system, right? We are the system. 

So, if you want to change that, we have to start with ourselves. So, part of deconstructing, you know, any person, place or thing is to take it apart, to see what makes it tick, what matters. And if we say that justice matters, then we have to ask ourselves, you know, let's say as a scholar, what in our scholarship or practice, you know, embodies justice. What does justice look like to us? And if we see that although we espouse justice, but we are not doing that justice work, then we have to change the work that we do. And we can only do that by deconstructing what we do, kind of analyzing ourselves, that critical reflection that we can say, you know, we are not who we say we are. 

And what do we have to do to change? And I think if you can look at yourself and say, you know, I'm not who I say I am and I need to make a change, then you have to make the change. 

And if we have to do that as an individual level, you know, in small groups and then as a system. But it starts with the personal. I am part of that is, you know, I do think that we're, you know, by and large that we are morally sound and good people. 

But how do our actions and practices and the policies that we uphold? How do they reflect that? And if they don't, then we have to ask ourselves, why not? So, you can't be anti-racist and be a part of the committee where, you know, it lacks diversity. 

But, you know, you say you're anti-racist. You know, being an anti-racist is a verb. You know, you have to do it. You can't just be it. You have to embody. You have to act on it. And then you have to hold people accountable to being anti-racist is not just for yourself, but it's for everyone. So, we have to kind of stand behind the ideals that we espouse and in real ways, and that's it is asking a lot. I said I was in a faculty meeting earlier and I said, you know, race is oftentimes a four dirty four-letter word. 

People don't want to talk about it. But if we don't address it, then it will, you know, continue to permeate, you know, systems, societies and places. 

So, we have to talk about the problem. America know that the Boyce noted in 1983, you know, the I know the color line, the problem with race and how we see racist practices, you know, reinvasion and reimagined again and again and again. And we hadn't really taken the time to seriously deconstruct, you know, just what does racism look like? Like, how does it play out? And then how do we write it? How do we make sure that, you know, we're being equitable and representing diverse voices and perspectives? 

So, I think it's important that we deconstruct our realities, who we say we are. And then, you know, rebuild ourselves, reconstruct, you know, because we can change but changes a lot. And it's difficult and it's it's scary. But I don't think we can continue like this. 

I think the pandemic has shown us that, you know, we need one another and we know who all we know who the vulnerable members of our community are. We know who is most impacted by the pandemic, by school closures. We know who didn't have even access to health care to get a ventilator or even could afford to stay home, like we say, that are essential. 

Workers matter, but many of them are underpaid and overworked. So how do we put our money where our mouth is? If they if they're essential, then how do we treat them? 

No, we being just have we looked at the policies that have created this underclass. And many times it's purposeful. So how do we make sure that everyone makes a living, not a minimum wage, but a living wage, and they have access to health care. 

So, when we deconstruct and reconstruct our realities, we have to make it personal. We have to look at, you know, our place in that and then we act accordingly and we stand on the side of justice, of righteousness. And that's what anti-racist is. You know, you have to act on it's not just saying no wearing a T-shirt and saying Black Lives Matter. 

How do you showed up? How does your work uphold those, you know, those ideals that black lives do matter? So, I love what you're saying about the need to be critical of our ourselves and our system and the processes that we're working within and our institutions. You've given us some ideas of how we can be critical ourselves. And I like what you say about. You said earlier about 2020 being a pivotal year. 

So, we're hoping that part of this podcast will help spur some of these critical takes and dialogs. And these ideas that you've been talking about are how we as faculty and how we as a as a university can be critical of ourselves and critical of us as a system. You've also in the past talking about or talked about from a student perspective that you want children to be critical consumers of their reality. So, can you talk a little bit about it from that angle? I think especially with students, we have to make it grassroots. We have to study policies that impact our lives. And when I say that, I mean that, you know, the personal that I you have to, you know, go into their neighborhoods, you know, in many urban communities. Unfortunately, there are food deserts. 

You know, you find, you know, liquor stores and corner stores, you know, on every block. 

So, we have to ask ourselves, you know, is there access to no fresh fruit and vegetables? 

How many agencies are available to give people different options or to offer resources and what's not being provided? And so, when students can see how oftentimes their neighborhoods are meant to, in many ways know entrap them, you know, they're not given other options, meaning there's no fresh fruit, vegetables. Look at the air pollution levels. Look at even in their own schools. 

How many teachers are qualified? How many teachers are meaninglessly qualified? They're not teaching in their subject area, or they don't have a master's degree or they're not, you know, content specialists like in which districts do we have, you know, highly qualified teachers? 

And then where do we have, you know, teachers who lack credentials and then look at suspension rates, then look at access to health care without with that data, looks like so is making students aware of the systems that in many ways encourage in and frame their realities and giving them the tools to deconstruct it. To say that, you know, I notice in my school, you know, we only have, you know, out of 100. 

We only have 50 qualified teachers. But in other districts know they're at 80 or 90 percent or even, you know, the racial diversity. We said diversity matters. And, you know, what does the teaching staff look like and why is it important that school leaders are, you know, really do their due diligence in finding, you know, diverse teachers and bringing in appropriate professional development and finding ways to connect communities to resources that are needed for those students and families. 

And so is simply making students aware of, again, the school community, their neighborhoods, you know, arrest rates, just kind of like what's happening in a real in a real way that affects them. What's the crime rate like? Was the unemployment rate like, you know, who's hiring? 

What are the services being provided and offered to the community? And how does that differ from what happens in other parts of the state or in, you know, in New York, see of the burrow, you know, or even, you know, in the in the surrounding states, in areas making students aware of there is an equity around us. And what will be our role in changing that? Because, you know, we're doing this not just for us before our children would be doing it for tomorrow.  

And we do that today by attacking those problems head on and looking at the facts, you know, looking at the details, because that's where the devil is, you know, best where, and that's where the inequities lie. How do we address that and bring that to the forefront of our politicians and policymakers and elected officials? And that's why voting is so important. So, letting them know we know which candidates are best representing their interests that are looking at, you know, the food deserts, the crime rates, the unemployment rates. 

Who's advocating on our behalf and who's not, you know, who earns our vote and who doesn't? Who do we need to change? You know, New York City, we had mayoral control. Maybe that's it in what has the mayor done? Let's hold him accountable for what's happening. You know, the hiring rates of teachers, retention rates, graduation rates. Who's moving on to the next grade level? So, we're just looking at again. 

The reality is that students must contend with in giving them the tools to make sense and to know what they need to be successful. You know, you need to have algebra one. In ninth grade, you know, and even if you don't want to go to college, you have to be prepared. You should by 12th grade, your reading levels should be at a certain place. You should have a certain amount of, you know, sciences with labs. Your school should have appropriate materials and curriculum and faculty. And if you don't, then know that these schools are not created with you in mind. 

You don't want to see you win it. But we're winners. And what are we gonna do about it? 

You know, and that's what we have to kind of know, feed the next generation, that they are critical consumers, but also that they can deconstruct and reconstruct their own realities to bring about change because change will have to live with young people. You know, every movement started with young people. We have to remember that and give them the tools to continue to lead. 

Tia Palermo: Wow. Yeah, those are some really powerful thoughts. So, what I'm hearing you say is that we as educators have a really important role in helping young people to see these realities. In terms of the statistics that you were talking about, these are things that people may not be aware of. And so how can we help raise awareness among our students of these issues? 

But you've also talked similarly about reconstruction of curricula. So how at the university do you kind of see this playing into what you're talking about here and helping that next generation become more critical about their reality? 

Terri Watson: Right. I think at the university level, one way to reconstruct curricula is by simply revising our curriculum. Now, oftentimes, particularly at the university level, the curriculum would require no death. So how can we introduce new and different perspectives and realities to push in and challenge students to think outside the box? 

We can only do that by introducing different thinkers like an education. Yeah. Doing is important, you know. But would Dubois, who is the father of sociology. What about Edmund Gordon? Like we have some thinkers, you know, who are like Edmund Gordon, many of us, you know, are still alive, that we have to look at those people who are advocating for change, whose scholarship is founded in the struggle. And that's who we study because this is a continuation of a struggle, you know, in many institutions, particularly education, if we're free to push thinking forward, then we have to use forward thinking scholars and many, many of those dead white men we study. We're very much about upholding the status quo. You know, they regurgitate old ideas. 

We have to go back. I think looking at, you know, black education and in looking at diverse scholars and I just know black books. But across the board, like, we have to ask ourselves, aren't we talking about who's missing from this, who's not at the table? What idea was contrary? You know, who said something different? And all oftentimes those people with different ideas probably look different and had different realities. And that's what we need to hear from what would have made would have made of scholars said about this. You know, what has no Hispanic scholars or Mexican scholars or just people who don't look like us? 

What have they said about it? Because the problem hasn't changed, but it's how we look at the problem and then how do we reconstruct, you know, the future? And I think we have to do that with diverse ideas and thoughts. And we can only get that from diverse people with diverse experiences. So, I think the scholars we have to welcome, you know, just different trains and thought leaders. 

That's what's going to show us forward. That's great. So, a call for us as educators to diversify our curriculum, to listen to scholars of color and people with different perspectives. So, thinking about how and again, this is kind of along the theme of how these are structural issues which are leading to these and equitable outcomes at the individual level. 

On the podcast, what Sheldon and you talked about the structural problem of racism, but how many of the answers to the problem are proposed at the individual? So, in terms of teaching young people kindness, mindfulness, resiliency, so why are these types of solutions a mismatch between, you know, what the problem is and these solutions that are being proposed? 

I think in particular, when we teach particularly kids of color and talk about teaching kindness and mindfulness and resiliency, I think in many times we are assuming that they don't they aren't kind, that they don't already have resiliency or that they're not mindful. 

I think the fact that they come from challenging environments, you know, they don't need resiliency there. They got up and came to school. That in and of itself is resiliency and kindness, especially, you know. Why do you assume that young people are not coming? I know now people say kindness matters or they have. They made kindness like a, this kind of benevolence that, you know, is like you are doing an act and you're doing it for a reward. 

You want a button or sticker order to check a box. But in many, particularly communities of color, we are community, meaning we trade on kindness that but to not be kind does not even into the paradigm. So, to assume that people and children of color are not kind or that's missing in their community. 

And I think we do them a disservice. And again, from mindfulness, you know, it's like thinking critically examine what you do. I think the fact that in many urban households, families are struggling to make ends meet, that they're, you know. On budgets and, you know, intergenerational and even housing arrangements like, no, that is mindfulness, they've thought deeply about it. They haven't just, you know, just kind of made this a one off. They have thought critically about how to make sure that, you know, the children are OK. 

So, to assume that no kindness, mindfulness and resiliency is not a critical part of who they are already, I think we do them a disservice. So, I ethnic instead, we should ask them about their realities and experiences and learn and build on that. We have to look at communities in children of color as asset rich people in contexts and learn what they're doing because that's what you know, the cultural disconnect is really palpable because we don't know enough about them to know that. 

Of course, they're resilient. Of course, they're mindful. No kindness. No, let's say this. I know growing up, it was, um, I'm the youngest of three children. And so, you know, my brother often works my sister and I to school. So, he made sure, you know, we crossed this street safely. We came home together. 

He waited for us. He asked us about homework like kind fullness and mindfulness and resiliency was a part of us growing up. Now, we looked out for one another. We know we took care of one another. We were latchkey kids. No. So we not only went to school and came home, but oftentimes you came cable to an empty house. We had to do our homework and have our snacks and wait for our mom to get home. 

So, to assume that, you know, you need to teach us how to do that. Look at what we do already. And that's what we celebrate and reward. And maybe, you know, help us improve in some way. But to assume that, you know, it's not already there. I think I think it's simply not true, particularly in communities of color where resources are scarce, where we are forced to be creative. You know, like we are a genius people by design. 

We've always made something out of nothing. So instead of assuming that we need you to teach us not, you better look at what we do already. And that's what we marvel. That's where the I think best practice should come from. 

Yeah, so I think what I want to do is I want to go back to this idea of I think you've talked in the past a little bit about how, you know, students of color come from these situations and these, you know, backgrounds where they actually do have a lot of resiliency. 

So how do you have any thoughts or suggestions of how, as university professors and college professors, that we can recognize those and things that we can do in our own classrooms to recognize the strengths that students are bringing to the table and maybe tailor our courses better for the diverse voices that we have in our classrooms. 

I think is simply listening to your students. I think too often, you know, I'm thinking about the work of Pablo Creary. 

We assume that our students are empty vessels waiting to be filled without realizing that they're actually quite full already. 

And we're simply enhancing was there. So, I think we do that by simply engaging in conversation, by being transparent and telling people who we are. Like sharing, opening up, using the eye, you know, talking about, you know, your experiences growing up in and finding ways that, you know, your realities in many ways intersect. 

Because what I found particularly teaching diverse students, is that I have far more in common with them than one would know that each of us probably thought, you know, on the onset. 

So simply finding ways like when I said, you know, I don't know about you, but I'm the youngest of three. You know, I grew up in a single parent house. So, I'm first generation. 

I know what it's like to, you know, to come home to an empty house because my mom worked two jobs. I know what it's like to tell my mom that come to the PTA meeting because, you know, she had to work. 

In fact, my mother told us just the opposite. She told us that if she had to come to school for us, we'd have a problem. So, when teachers thought that, you know, oh, well, this young mother doesn't care, it's quite the opposite. Not only did she care, but she told us if we did not act accordingly, that, you know, we would have a problem. So, the good behavior that teachers saw, that was parent involvement, because I knew that if I acted any other way, that my mother would not have that. 

So, I think, you know, it's looking at the inherent cultural wealth that's in every child in the classroom. Now, we have to assume that they come from loving and caring homes and that our job is to celebrate that to to make them proud so that they know that I never once the mother didn't care. I knew she was working two jobs to make sure we were OK. 

So, let's celebrate my mother and in shame on those system that underpaid her, that she had to get a second job at that first job. She couldn't make a living wage to take care of us. So wasn't my mother. 

But it was the system she was working against. And I understood from her, you know, resiliency, you know, kindness, mindfulness, the fact that, you know, she called us when she thought we should be home and asked us what we were doing and how she found the time and her workday to check in on us. 

And she had to come home early. She did. But it was understood that she was losing money. And so we really tried to lessen the burden of, you know, taking care of us. 

We knew that in school. We could, you know, we could do our work. We could be, you know, upstanding citizens. And she believed in us. So, we worked together. So, if that's not community, if that's not kindness and grit, then I don't know what is. But when teachers say that, you know, students need that, particularly students of color, that you're not looking at the cultural wealth of that child and his or her family. 

So, I think the best ways for professors to kind of unpack the cultural wealth that's already in their classroom is by simply talking to their students in real ways and finding out who they are and why they are even in college and what they hope to gain from this experience. And I think once we have that relationship, then the learning can happen. But if you don't know who your students are, then how can you reach them? 

How can you speak life an agency and let them know that you care about them and that we have this, you know, this community that we form? You know, the heart of that is relationship. And we do that just by listening to one another. We'll have to do that. I love how you're talking about this culture of, well, that kind of turns on its head. 

Another ideology you've talked about, which is deficit ideology is where we often look and see problems. So, kind of similar to that. What do you think we can do in our own work to challenge this idea of deficit ideologies? I think we have to you know, we have to mine for gold. We have to go in assuming that, you know, all parents care about their children, that that and that kids want to learn. 

And more importantly, they have the capacity to learn. Our job is just to find new and creative ways to learn and grow with them. And that while we're teaching, we're also learning and growing. And we have to be graceful, not just with our students, but with ourselves. 

And I think we do that by, again, looking at our students as goldmines in our our real challenge is how do we. How do we find that goal? What can we say to spark the conversation and creativity? Because it's there, but it's our job to try to make it shine, to bring it out and to show them how to move in the world, because particularly as a scholar, color a big part of what I do. 

Simply telling my story, you know, so that you can notice this. You know, we in many ways we demystify the academy. You know, I'm first gen. I know what it's like to be counted out. I know that when I told my colleague, my, um, my advisor in high school that I wanted to go to St. John's University, he was like, oh, you'll never get in. 

She didn't believe in me. So, part of my job was to make sure that I got in and came back to tell her, oh, guess where I'm going. You know, in the fall, because I knew that, you know, she didn't think that I could do it. So, I think a big part of what we do, is that that we are dream keepers. 

You know, we have to harvest and keep young people dreaming. We have to dream with them, believe in their dreams. So, when I tell you what they will be, you buy into that. You don't agree with them. Tell them, yes, you can, and then show them how they can do so. 

Tell your story and help them find their own story. But our job is to nurture, to care and to dream, you know, and I think that's missing in many communities of color. 

We stop dreaming with young people. We stop believing in young people. We don't see that they are gold mines literally in our presence. We think that they are broken, and we need to fix them. Young people are not broken. We have to fix our mindsets and move away from these deficit ideologies that we've been taught in the academy that these are broken or disease people. 

No, not at all. We are rich and resilient people. And I think well, maybe. Sorry. I think maybe that comes from also how we're always having to frame a problem, right. So, with that search, we also we always need to see what the problem is and how we can generate evidence which helps provide solutions to these problems. So, I like how you're challenging us to think about this. You know, it's interesting you should say that because the Spencer, they just released the funding opportunity and the funding opportunity. 

It's a racial equity special. Right? A racial equity special research grant initiative. So, they're looking for ways to do that. They're looking for ways to fund promising directions for engaging and supporting children, families and communities. And I think the best way to do that, like in solving any problem, we have to go to the people who are most impacted by the problem because they are working on solutions and real meaningful ways because, you know, their lives depend on it. And I think that's why we have to go back to the community, go back to the people and see what they are doing. 

You know, in real time. And that's what the solution is. Too often we come at problems with this top-down perspective, because if you don't live in these communities and how can really understand or even frame the problem, to say that it's a problem because what you think is a problem may not be for that particular community, could be something totally different. 

And what you're seeing is an outcome of the problem, but not the problem in and of itself. 

So even defining the problem, I think we have to go to the community and ask them what do they feel the problem is and how have they thought about addressing it? 

And then how can we lend our intellectual talent to marry what they are already doing? 

Like, we have to go to the community, like they already have the answer, because, again, they are closest to the problem because their lives depend on it. So, they have a vested interest in solving the problem. 

And for I think we search as many of us, we don't live in the communities that we study are a part of it, know we are outsiders. And that's bad in so many ways because then becomes you know, we come in at a handicap, like we're doing this community a favor or, you know, they are a problem, and we are here to fix them without realizing that you don't think they care like you think it doesn't matter to. Of course, it matters to them. Of course, they've tried addressing it and I'm delighted to see what they have done. 

And then what can we do together that may improve it? Like, how can we add to an already rich resource and it's just how we frame it. You know, we have to you know, too often we think that we are the light and we're not. And many times, you know, I think we don't celebrate the community enough. But this is a really, I call this is really a call for more community based and participatory research methods. 

Exactly. Too often we are outsiders studying the problem at a very esoteric level. We have people who are living with their day in and day out and trying any and everything. 

And that's where we really need to lend our intellectual talents to work on them. I want to tie this back to something you said earlier when you were talking about community involvement and service and how as universities, we need to make our institutions relevant. Can you talk a little bit about how maybe some of this community and service work can help make our universities more relevant to the communities that we're trying to serve? I think that for many of us, we have to reframe. 

You know, unfortunately, in the academy, you know, we are very ego driven. We don't want to be you know, we want to be the biggest and the best and the smartest. But you know what we learned in leadership, and I think you said this, but leadership must be embedded in service. 

And if service is beneath you, then leadership is beyond you. So, if we are to be forerunners, then we have to ground ourselves in service. And that means not working for the community or speaking to the community, but as working with the community and speaking with the community and more importantly, becoming part of the community. 

Like we have to truly invest in those, you know, we claim to want to serve because what we do, particularly if we are to change, you know, change lives, you know, its service. But in changing lives, there's reciprocity in it because we become better, our scholarship becomes more informed. But we have to, again, go back to the community because that's what's going to make us better. 

And part of that is being humble, saying what we don't know and understanding the community and the challenges they face. Looking for ways collectively and collaboratively to address those problems. But too often, as researchers, we come in with the answer. You know, we have the funding and we're going to throw money at it. But that's not really addressing deeply rooted problems. 

And we can only do that by being in community and understanding kind of, you know, what's exacerbating the situation. And then, you know, how can we, you know, think with them to address it? Like we don't have the answers that that's not that's not the right framing of the problem. 

You know, here's the situation and then we have to look at the participants in and see how we want to change the outcome and the reality. And that has to be a conversation that has to be about trial and error. It's not a one and done. You're not going to come in with, quote unquote the answer and then, you know, magically, you know, the situation is right and that's not going to happen. 

I think you're right that as researchers, we do kind of have these big egos. And I think even if you're a person that's not necessarily has a tendency to have a big ego going into it, the way that success is measured and the way that you kind of go through the system, it makes you kind of be that person that pays attention to, you know, these measures of success. So, thinking about how we measure success as academics, you know, it's really about publications and grant. 

Yeah. So, what did you as an individual? How much money are you ringing in and how many publications did you have this year? So, thinking about the criteria in which we judge academics. Do you have any thoughts about how we can move the dial on these criteria to maybe make it more engaging or recognizing some of the very important and time-consuming work that scholars are doing? 

Younger scholars, scholars of color? How can we recognize those efforts to make them successful in the system? I think we have to revise the standards for tenure and promotion. You know, too often is about quantity. It's like how much money, you know, how many publications. Instead of looking at the qualitative aspect of it, like where is the work, you know, seated? Who are you working with? And how are the outcomes applicable to real, real-world problems? You know, oftentimes, you know, we're so theoretical. Our work is sometimes so absent of practice, not across the board. 

But what I found by and large is that, you know, we all have these grand, grandiose ideas that we speak about and create this utopia without looking outside our windows. And in many of these institutions are, you know, so removed from, you know, everyday people, particularly those who could really use our scholarship. 

So, I think what would makes it I guess what makes the academy or doing this kind of qualitative, meaningful service, deeply rooted in service work in studies, is that, you know, you won't get the big bang, you won't get the you know, the publication in a you know, a tier one journal or you won't be at an hour one. 

I think we have to look at not what we do, but why we do it and ask ourselves how does this leave not only the people that we hope our research will impact, but how does we must better make are we more thoughtful? Is our scholarship, you know, does it really matter like this? It's like I'm pretty sure that you're someone is going to be fine. And I know my daughter just graduated from Tufts University, so that's cool. But I'm not really trying to talk to you. I'm trying to talk to the people in those mom and pop stores who live in food deserts who are first gen. 

Like, that's where the real change is going to happen. So oftentimes, you know, the academic journals that we publish in and the conferences that we go to talk about our work. 

They don't affect the people that we care most about. So I think if we're really to to change the focus of the work we do, then, you know, unfortunately, we can have to change the guidelines for tenure and promotion. We have to see. No. Why do we give you know, like we talk about service, you know, service. 

Where is it? A university committee or service in the community? You know, like how is how do we define service and what does it look like in a publications should be published in a tier one journal or should it be a union newspaper or for public consumption? 

You know that we really talk to people who don't have PTSD, who aren't, you know, whose university does not subscribe to this particular journal, you know? Is it a grass roots community based Forward-Looking publication or is it, you know, written with academic standards that, you know, the common person just won't get? 

And I know from myself one of the things that I promised myself, that if my mom with a with that with the high school graduate high school degree, like if my mom can't read it, then I should write it. I want people I care about to be able to understand, you know, the ideas and thoughts and methodologies that I'm using and writing about and spending so much time on. So, people I care about can't read it and I don't want to write it, that I have to find ways to make my language accessible and more importantly, that the work I do matters for those I care most about. So, we have to kind of reframe even, you know, tenure and promotion and what's quote unquote research.  

Tia Palermo: Absolutely, wow, you've. You've given us so much to think about today.  

So, what I want to do is I want to give you an opportunity to just maybe follow up or or, you know, is there anything that you want to say that you haven't been able to say? 

And I just again, I just want to thank you for being with us today. It's always a pleasure to talk with you.  

The first time you and I met, you were giving a talk to a group of faculty, and it was VSL in a breakout session. And I was having a rough week and it was a Friday afternoon. 

And you just gave such a fiery and inspiring talk. And it was similar about, you know, doing work that's meaningful and being true to yourself and making a change in your community. 

And it was really just what I needed to hear at the right time. And so, it's been such a pleasure to talk to you again. You've given us so much to think about and unpack and ways that we can be critical in our own lives and our work with students and how we can really make small changes that can make big differences. So, I really do thank you for everything you've said today. I just want to give you an opportunity, you know, if there's anything else that you want to tell us before we have to go today with those kind words. 

Terri Watson: And I just remember that conversation and, you know, I guess I practice what I preach, you know, what matters, matters in everything, matters like something always matters to someone. And I never I never disregard that. So, I tell people, you know, do what matters for you. You know, speak like speak truth and make sure they all reflect and resonate within you, because then it will always matter, and our work will never be in vain. We spend a lot of time doing this work. 

A very big portion of our lives is scholarship, is the reading, is the writing, is the, you know, unpacking what we've learned. And if we're not, it doesn't matter. Then why are we doing it? You know, like who does it change in? And if it's not changing and changing. 

If it's not improving, then the realities in life outcomes of people and communities that we care most about, then it's all for not in my perspective. 

So, for me, I always ask myself, you know, is it important? Is it important to me? Doesn't matter. And nine times out of ten, nine times out of ten it does. And so, I put my heart in it. And I think we have to go back to that. I think we have to put our heart in this world, you know, like I I love people, you know, and I love black people in particular. 

So, I'm going to do my best not to show up and to speak life. I'm going to speak love and win. 

And even if it doesn't work, know that I cared. I tried. And this is my best. And I feel good about it, you know, and every grant that goes unfunded, every project that goes left know that I came in with an open heart and my job was always to be of service. 

And I tell people that, like, that's what I'm looking for. Well, I'm looking for the asset. 

I'm looking to celebrate the good work you already do. So, it's never a aha moment. 

You know, I don't I don't. Do we call it deficit data? I'm not here to tell particularly black, black and brown people that they are broken. That's not my job. That's not what I do. 

I'm here to tell you that you're awesome, that we are awesome in this research will simply highlight the good work you already do. If my people can't read the work that I do, the why am I doing it? Because, you know, I am my people, you know. And that's important. We have to remember the communities that we come from, particularly ourselves, sellers of color. 

You know, we didn't get here by ourselves. I come from a long line of beautiful black people, and my work will always reflect and celebrate that. And that's important. And I hope that others find a similar, you know, important. It's an agency in their own work. You know, find the beauty, find a true speak like, you know, speak life for people who care about. 

Tia Palermo: Love you through this because that's how we got here. Dr. Watson, and it's been so fabulous talking to you today. You've given us so much to think about. And as always. Just very inspiring. So, I really thank you for your time today and for our listeners. 

Dr. Terry Watson is associate professor of educational leadership and the Department of Leadership and Human Development at the City College of New York. You can look up her work there. And this year, she is also a Center for Diversity Innovation, distinguished visiting scholar at the University at Buffalo. 

So, again, Terri, thank you so much for being with us today. Thank you. 

Intro 0:00 
Hello and welcome to Buffalo HealthCast a podcast by students, faculty, and staff of the University at Buffalo School of Public Health and Health Professions. We are your co-hosts, Tia Palermo, Jessica Kruger, Schuyler Lawson. In this podcast, we cover topics related to health equity here in Buffalo, around the US and globally. In this first semester of the podcast, we're taking a deeper look at racism and health. We'll be talking to experts around the US as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population health and wellbeing. You'll hear from practitioners, researchers, students and faculty from other universities who have made positive changes to improve health equity and inclusion.

Schuyler Lawson 0:47 
Alright, so hello everyone, and welcome to another episode of Buffalo HealthCast. I'm your host, Schuyler Lawson, first year PhD candidate in Community Health and Health Behavior. With us today is Stan Martin with Cicatelli Associates Incorporated, and Ebony White with the African American Health Equity Task Force. Thank you both for taking the time to be interviewed today. It's great to have you. So first off, can you tell us a little about yourselves?

Stan Martin 1:19 
Sure. Why don't I go ahead and start us off?

Schuyler Lawson 1:24 
Sure.

Stan Martin 1:25 
Thank you, Schuyler, for the opportunity to be a part of the podcast and to share our program. Once again, my name is Stan Martin. I am a Project Director at Cicatelli Associates. I'm a native son of Buffalo, I like to say, so I've been away for a few years and recently moved back home, back to Buffalo, a place that I love and that's near and dear to my heart. So, I'm looking forward to having our conversation today and share some of the work that we're doing here personally, as well as professionally. So, thank you.

Schuyler Lawson 1:56 
Great, great. And how about you, Ebony?

Ebony White 1:58 
I'm Ebony White and I work with African American Health Task or Health Equity Task Force. So, a lot of acronyms out here, and I have been working in the community for over 10 years. Most recently, I do a lot of work with the barber and beauty salons. That's where people first were introduced to me doing my work and spreading all the education and knowledge to build health knowledge in building the capacity in our very own community. And I am a native of Buffalo, New York. So, thank you this morning for having me.

Schuyler Lawson 2:34 
You're very welcome. I was going to ask you about being a Buffalo native, but you already answered that. I'm pretty fond of Buffalo too. I'm not a native, I'm actually an Alabama native. Birmingham, Alabama.

Stan Martin 2:50 
Yeah, we won't hold it against you.

Schuyler Lawson 3:03 
So now, I have another question. This one's more for Stan. So what is the mission of your organization, CAI?

Stan Martin 3:16 
Yes, it actually is not my organization. I wish it was, but CAI was founded by Barbara Cicatelli over 40 years ago. Our headquarters’ in New York City, we obviously have an office here in Buffalo, New York. Albany, New York. Atlanta. Denver, Colorado, as well as LA (Los Angeles), and we also have several satellite offices in Latin America, the DR (Dominican Republic) and El Salvador. So, a lot of our work that we do is global, not just domestic. And our mission is really to utilize the transformative power of research and education to foster a more aware, healthy, compassionate, and equitable world. So, it's a pretty lofty goal. And yet, it still is something that we thrive in terms of working towards. I look forward to doing it on a day-to-day basis. So, I'm very proud to work at the organization. I've been with them for, actually, going on 10 years now. So, it's very rewarding and gratifying. So, thank you.

Schuyler Lawson 4:25 
Those are impressive goals. And that's also a very impressive tenure, about 10 years. Very nice.

Stan Martin 4:31 
Yes, especially when we talk about reaching out, I should emphasize that our focus is on marginalized communities in particular, who have some of the greatest needs and the least amount of resources. So, given all that's happening in the world today, it's very gratifying.

Schuyler Lawson 4:53 
That's definitely an important group to focus on. Shows there's still a lot of work that needs to be done. Actually, that's a good segue to my next question. So, CAI recently received a $2 million grant from the US Department of Health and Human Services Office of Adolescent Health, to focus on improving the lives and opportunities for adolescents by facilitating and resourcing a community driven response to reduce teen pregnancy in select zip codes in Erie County. Can you tell us more about how these zip codes of communities were chosen? And also, what barriers those adolescents face to getting accessible sexual and reproductive health care services?

Stan Martin 5:38 
Thank you for the question. I think I should probably, as we say, utilize the sankofa principle; let's go back to go forward. So actually, the grant itself that you're referencing, our teen pregnancy prevention grant, through the Office of Population Affairs now, actually started five years ago. And it was really focusing on nine zip codes that had high rates of disparities of teen pregnancies, as well as STIs. And I want to preface it by saying, not that there was something going on in these nine zip codes, that weren't going on outside of these nine zip codes in terms of adolescent health and reproductive services. The important element, in my opinion, was that, having access or access to information, having access to resources, and dealing with the root causes of teen pregnancy, and also STIs, as well. So, when we look at the root causes, then that allows us to not only look at why someone is getting pregnant or getting an STI, but what is it that have precipitated that experiment. So, looking at education, looking at access to housing, looking at, believe it or not, like I said, housing, looking at employment opportunities, looking at the social determinants of health, as the root causes of some of these issues that we're facing, as opposed to looking at from the opposite lens, as being a teen parent, or a teen father, and then resulting into some of these other social determinants. So, having said that, when we started the initiative, we really went to the community and wanted to ask the community, how could we implement this program in a real authentic, participatory way? And after doing several listening sessions, conversations in the community, one of the things that resonated with the community, that came out of those discussion was HOPE. And Buffalo was, at that time, within the middle of this renaissance, but people were feeling like they weren't a part of this renaissance. So, HOPE actually stands for Health; making sure that our adolescents and adults have access to quality health care services. Opportunity: the opportunity to receive a quality education, opportunity for job employment, for placement. Prevention: if we can look at the root causes of some of these factors, and we can prevent it and promote a healthier lifestyle, why wouldn't we? Last but not least, E for Equitable; it's not all about being equal. It's all about addressing the health disparity through a lens of equity, so to speak. So that came from the community and utilizing those concepts and those principles actually provided us opportunity to create a brand, in terms of HOPE Buffalo, for adolescents, for adults to wrap their arms, provide wraparound services to adolescents, and build a stronger, healthier, thriving community. Which led us to get refunded, just this past July, for a second round of really looking at how do we look at system change, policy changes that reinforces the environment that I just described to you, where every child has an opportunity to succeed, and access to quality health care services.

Schuyler Lawson 9:20 
Given that you've been refunded, I assume that there's been some progress made in addressing this particular issue.

Stan Martin 9:30 
Yes, when you look at what, for my five year program, my first initial cohort, we're crunching the numbers right now to look at where we are in terms of our nine zip codes. We know that, overall, that our teen pregnancy rates are the lowest that they've been in 30 years, which is saying a lot. And we also know that, as you mentioned earlier Schuyler, that there's still a lot of work to be done. We're proud of our successes in terms of being able to refer and make use of services to partner with other community organizations, including the Buffalo Public Schools. When you look at the enrollment of the Buffalo Public Schools, over 50%, I think close to 70% of the students, live in poverty or at the poverty level. So, it's very important that we are engaged in the conversation. In addition to working with health care providers, making sure that they're meeting with leaders, students, adolescents, where they're at, and that is sometimes a challenge. And yet, it's still, it's the goal they'll understand that, as adults, our children have rights, especially here in New York State, when it comes to reproductive health and the amount of services and privacy and confidentiality. So, we still have a lot of work to do. And I look forward to coming back on other shows, and pointing and sharing some of those numbers with you.

Schuyler Lawson 10:56 
Absolutely, I look forward to that too. There are so many projects that this organization is doing, so it would definitely probably constitute multiple episodes to just adequately cover them all. Okay, so now, I did have a question about - you mentioned social determinants of health, and that's a great topic. That's talked about a lot at the UB School of Public Health. So regard to this particular project, what have you found are some of the social determinants of health that are sort of easier to address, like, for example, housing may be a heavier lift, as far as maybe addressing that, but are there some others that are kind of some of the ones that you focus on more readily, because they're, maybe, so to speak, lower hanging fruit that can be modified?

Stan Martin 11:46 
Well, this work is very complex, so I don't know, necessarily, if I will use the term "easier". What I would say, what's really important is that the youth and the community are involved in everything that we do, and every decision that we make. From branding to the delivery of interventions, to know how things are marketed. So, I think that is a critical point and critical piece that I would like to really shine a light on. Because when you look at COVID-19, when you look at where we are today, and how that has shined a light on the disparities that are impacting our community in terms of health, and chronic disease, etc. Essential workers- it's very important to have those, as we say, those contacts, those with those real-life experience at the table, and that they are involved in the solution, and not always seen as a part of that problem. So, that has been, I would say, very important in order to address the social determinants of health, and then to eliminate some of these disparities that we've talked about thus far.

Schuyler Lawson 13:03 
Thank you. So, my next question is, what is the Tobacco Free Coalition? And what role does CAI play in it?

Stan Martin 13:15 
Well, you know what. Can I sit with that question for a moment?

Schuyler Lawson 13:18 
Sure, sure!

Stan Martin 13:19 
Because I really want to - I would like to invite Ebony into the conversation.

Schuyler Lawson 13:25 
Sure.

Stan Martin 13:25  
She could speak for herself and has a lot of experience at the individual, at the community level, as well as the policy level as well. So, if you want to chime in or share a few words, in terms of working with adolescents in this area, or in our community, your experience, kind of addressing the social determinants of health, please, feel free.

Schuyler Lawson 13:48 
Absolutely.

Ebony White 13:49 
So what I will say, in reference to addressing social determinants of health, generally, we have focused on education, transportation, access to adequate health care. And primarily, I've worked between adolescents and adults, all the way to geriatrics. So, trying to make sure we're working through community health workers have been pivotal in actually being boots on the ground and coming back, and helping us develop strategies that really assist to minimize those barriers. A lot of barriers are, of course, our education around it, and trust issues with our healthcare system. So, I think I spend a lot of time getting word of mouth right from them. And I'll show back up at a meeting table and say, hey, listen, that didn't work. That strategy didn't work. It missed the group that we were attempting to support. So that's why I think it's very important to have those listening sessions, those focus groups, and come back to make sure that everything that we're doing is being helpful. I want to be going in the right direction. People improving their health, as it pertains to chronic diseases. So, as I mentioned, in my introduction, I spent a lot of time in hypertension, assisting with hypertension in a barber shops. We just started the conversation in those barber shops and salons and that conversation kept buzzing around, and just how important that is. And it's the same way, currently, we're doing with starting those conversations about our initiative. And I think we're going to segue right on to start talking about the REACH initiative, and all of those other things. So that's most of it. I get right to the people to make sure we we're getting the appropriate questions, we're addressing those barriers, and those misunderstandings, if you will.

Schuyler Lawson 15:38 
I like that you mentioned the barber shop. That's an interesting - that's a good social location to reach African American men, and I think that's a really novel approach at trying to do outreach, as opposed to maybe some of the more traditional approaches. Have you found that to be more successful?

Ebony White 15:57 
I've found it to be very successful. So, we were able to do it in Erie County as well in Niagara County. What we found is those barbershops held those very intimate conversations, but we wanted to make sure that they had the right information. And we were able to work with another federally qualified entity to navigate individuals there. Because sometimes the health care provider wouldn't know some of the issues that men and women were having, but their barber would know, so it was intriguing. So my job was to make sure we gave them all the right information, gave them all the right tools to navigate to healthcare to get their needs met.

Schuyler Lawson 16:40 
Yeah, and that is a great segue into our next question. So, CAI and the African American Health Disparities Task Force both received annual grant funding, through 2023, from the CDC to address health disparities and rates of chronic disease. And this project was known as Racial and Ethnic Approaches to Community Health, REACH for short. Can you both tell us more about this ambitious project?

Stan Martin 17:11 
Sure. I think you hit the nail on the head earlier in your introduction. REACH is funded by the CDC, and when you look at health disparities here in Buffalo, in particular, we're one of 40 recipients from across the country that's working on reducing chronic disease amongst African Americans, as well as, I would say, communities of color specifically. So, we look at them, think about cancer, diabetes, asthma, hypertension. Who are those individuals, those communities that are most affected by it? So here in Buffalo, our selected area, or, as we like to say, our area of focus, not just in terms of ethnicity, looking at geographically, it's across five zip codes here: The 14208, 14209, 14211, 14213, 14215 communities, and those community in particular, in chronic disease, startlingly, are 300 times more likely to have or, to be impacted by one of those kinds of disease, if not more, as opposed to those who live outside of the community in particular, white people. So, therefore, in order to address that health disparity, we've partnered with the African American Health Equity Task Force to look at not just how we can address those health disparities, but as I mentioned earlier, how can we eliminate those health disparities by focusing on the root causes of them? Now, I like to use analogy that some people may have heard before, where you have this community that's impacted, you by these health issues. And when do we finally say, for example, what's in the water? What is it that they're drinking? What is it that they're consuming before we finally actually go to the well and look in the well, what is the root causes? Utilizing that analogy, they say that we have to start going to the well, and saying what are the root causes, addressing them to eliminate them ultimately for communities that are disproportionately affected by them. So, Ebony probably would like to share some of her thoughts as well. So, I will go on mute and turn it over to you, pass the time to you, Ebony.

Ebony White 19:44 
I totally agree with everything that Stan has shared - definitely getting to the well. Our listening sessions are opportunities for us to get to the well and figure out what's happening within our own culture, within our own behaviors, in those particular zip codes, and trying to shift. Trying to change many of our behavior patterns as it pertains to cardiovascular health, diabetes, cancer, all of those things that plague our communities year after year, and there is more and more data that says - I'll give you this. I was sitting in a meeting, and they were showing some data about, if you are this age, you won't live to this age, because you'll more than likely be impacted by this, this and this. And I'm thinking, wow, they can literally project that I'm going to be a goner? Because I live a particular way, and I live in a particular zip code. Wow. I just didn't feel comfortable. And that was my push to educate my community more. Someone is sitting in a room, and they can, based upon your behavior, you're going in the direction that you will be gone before you're 62 versus your counterparts that live in different zip codes. That was my "aha" moment. That someone had that ability, that power, because of my behavior, or in people just where I live, that that would be the outcome for me. Then I said, not so, not so. So, I do everything I can to educate, whether it's in our faith community, our medical community, our small groups, our pockets, our barbershops, our salons, our businesses, to make sure that is not the narrative for my community. So, REACH is an acronym, but it's a beautiful word. So I'm reaching over, I'm reaching in, I'm going deep, I'm going under, I'm going high to doing everything I possibly can, through our strategies and innovative ways to get that communicated to our community members, our concern for them overall.

Stan Martin 22:01 
And if I can just ask - thank you Ebony. Some of those strategies that we're doing implementing, thinking about increasing access to food and nutrition, addressing the issues of food deserts that are in our community, and how do we work with those businesses, those retailers, those barber shops that are in our community, to ensure that they are all capable, have the ability to provide access to fresh fruits, and vegetables? So, food and nutrition, as one of our strategies, our area of focus, and another component of that, that we don't oftentimes think about, that has huge implications on one's development, is breastfeeding. Something that really early on from onset, from the cradle, through maturation, can have significant health benefits. So, educating the community on the benefits of breastfeeding and providing access to those peer groups, so that women, as well as fathers, who can be a part of the conversation to encourage a healthier lifestyle. Also, we're working closely with health care providers to improve our community and clinical linkages, or relationships. There's a lot of historical traumas when you look at Black and brown communities. That really presents a barrier for us to have bidirectional, two-way conversation. So how do we create an environment where there's trust, where there's rapport, where it's authentic, that we can have these open conversations, and that doctors, our physicians, health care providers are meeting their patients where they're at, and not closing and keeping at least the lines of communications open for that behavior change that avenue to describe? In addition, there's no secret from my lens that there's disparities in terms of tobacco use. Those who live a certain lifestyle, in terms of income, and education, are disproportionately affected by tobacco now, and tobacco is also heavily marketed or advertised in communities of color, more so than in other communities. So how do we not only reduce the prevalence of tobacco use, but also increased access for those who want to quit, to quit in terms of tobacco cessation? So, we're trying to create change at the individual level. Also, we have to also address the built environment. The environment has to change, that supports the behavior change, and something that Ebony always oftentimes talks about, how do we provide opportunities to maintain and to sustain that over a longer period of time of lifespan? So those are just some of the strategies or areas that we're focused on. To improve health and wellness for residents who reside pretty much and along the Ferry Street corridor, from Bailey and Ferry, to the foot of Ferry or as some say today, Broderick Park, and I would say 4.4 miles along the Ferry Corridor, and East, North and South of Ferry as well. So it's roughly like a 4-mile radius.

Schuyler Lawson 25:26 
Thank you both for providing detailed descriptions of the REACH program and the extent of its reach, which is now quite remarkable. I have another question about the REACH project. Do you have any notable milestones that you'd like to report, as far as the progress of the REACH project?

Stan Martin 25:52 
In terms of milestones, I would like to say, due to our partnership with the African American Health Equity Task Force, we've been able to be recognized by the CDC for our work as a model within a short period of time. We're actually in year three of a five-year grant. And because of this partnership that we have with the Task Force and the community, we had an opportunity to apply for some supplemental funding to address the disparities surrounding flu vaccinations. So, if you don't mind, Schuyler, once again, I like to pause and just ask Ebony to talk a little bit more about that from her perspective. And to me, I think that's a project that we both are very excited about. And then we have some things that we're working towards that we want to share with folks.

Schuyler Lawson 26:50 
Yeah, and it's very pertinent too, especially in this time of year for flu season. Absolutely.

Ebony White 26:55 
Correct. So, that supplemental funding, as it pertains to flu vaccination has given us the opportunity to partner with Dr. Vasquez in Urban Family Practice, different pharmacies, faith communities, and one of the large business entities that has kind of showed up in the city of Buffalo, is giving us the opportunity to work with their mobile unit to actually get access for flu vaccinations and give education around flu vaccinations. We are at a pivotal time; we've never been in a pandemic. So, we have COVID-19. And then we have the flu. So, what we're trying to do is educate our community about the importance of making the choice. So, I want to give you the education, but it's always your choice. But when you do it, and you make that choice, you're doing it with you in mind, your family in mind and your community in mind. And I think that is a conversation that generally has not happened around flu vaccines. People are asking more questions and questions are good. Why do I have to have it every year? I feel like I see more signage about it. Why? Because it's important, because we're in this different time, this pandemic time. And we want to keep you safe. We already have adopted a lot of safety measures - hand washing, masks. We've been giving out food and nutrition actually, during those mobile unit events. We've been to some of the faith communities all the way in Lackawanna, and a couple of more in the city of Buffalo, distributing flu vaccine, shingles shots. If people are asking questions and trying to get back on track with their medical care. So, what we look forward to doing is making sure that, if that is the intersection that we meet in our mobile units, we want to make sure that we give you the education to move forward in maintaining, and the maintenance of your health care going forward. So, in the upcoming months, we are in we're actually we're embarking on the peak of flu season, which will start December the 6th. So, we are encouraging people - I know this is a really hard time. You're telling people to socially distance, avoid, but nobody wants the flu, not alone. We don't want COVID. COVID has impacted pretty, much touched everybody's home one way or another. You know somebody, it may be you that has been impacted by COVID. So, we were trying to get the word out as much as we can, just for our community. We don't want - we know what COVID did to our community. It impacted our Black and brown communities at a much higher rate than it did our counterparts. So, we want to bring that down. We want to bring that down. We want to change the manner the direction that the data is showing, if we don't. So, we want to make sure it's about education, it's about your choice. It's about your family, and it's about your community. So, Stan, you want to jump in?

Stan Martin 30:11
I think you hit the nail on the head. Like you said, we do our listening sessions, having conversations, Ebony has met with the community. They said that they felt as though it's important that the community have this information, that people recognize that they do have a choice. And what we've heard, as Ebony eloquently shared, was that people aren't only concerned about themselves. They were concerned about others. And that message of having love for your family and for others, your community, is something that they thought that they could champion and rally behind.

And just some of my, as I like to say, my one show surveys and talking to pharmacies and providers, that they are seeing more people getting vaccinated. So, we're looking to continue to march our campaign on our conference meeting campaign through platforms such as this, radio, TV, as well as in print, and then in the weeks ahead and even into the New Year as well. So, stay tuned. 

Schuyler Lawson 31:17
All this is very encouraging, and I really do hope that it leads to higher vaccination rates in those marginalized groups.

Stan Martin 31:25
Well, you know, Schuyler, as we mentioned earlier, we really have to address the trauma. You know, when people say that "I had a reaction towards getting shot." People aren't aware that also there's a nasal spray that's available or, is this someone 65 and older? There is a different vaccination that they receive as opposed to someone younger. And it's one of the things that prevalent and I hate to pick on Ebony - she always reminds us of if Mama said it or Grandma said that, their opinion matters. You can't go against Grandma, you can't go against Mama because that shuts down the conversation. How do you have that conversation in a respectful way that really says, okay, I'm not throwing Grandma or your mom under the bus, and I want to recognize that providing information that dispels some of those myths. That's critical in terms of people making that change, and it may not happen right then and there. And I think what we're say saying, different points of intersect is occurring that we're encouraged by. Knowing that and having those trusted - having an Ebony, having a Dr. Vasquez, to meet someone in a barber shop or a salon or a place of worship. Not on their Sunday though, but to meet them in their comfort zone and share information in a nonjudgmental way is important.

Schuyler Lawson 33:15
It appears that a thread that I'm seeing for all of these projects is the importance of meeting people where they are and having sort of a community participatory approach addressing these very unique issues. Would you both agree?

Stan Martin 33:31
Absolutely.

Ebony White 33:33
Absolutely.

Stan Martin 33:35
And you know, I know you're very versatile, I believe you're very versed, Schuyler, and a community participant in practices and approaches. And we also utilize collective impact as a part of that. Collect, for those who may not be familiar, having a shared agenda, bidirectional communication, a combination of coordinated strategies, having a backbone organization. CAI and the Task Force, the African American Health Equity Task Force, working collaboratively together and being able to provide resources and utilize science and data in a manner that we aren't weaponizing or victimizing and traumatizing those we're trying to reach. Those are critical elements, moving from implementation to creating a movement. Any movement that's successful, in my opinion, including the Black Panthers, you have to start at the grassroots level, and you have to have the community's trust in reporting that. And those are just some principles and frameworks that we embed in all of our work across the board here in Buffalo.

Schuyler Lawson 34:50
Thank you both for sharing more information about this very important project. Did you have anything else you wanted to speak to us about, particularly about the vaccination initiative

Stan Martin 35:04
I want to say, get your shot. If you haven't already, get vaccinated, get the shot to protect yourself, your families, your loved ones, and your community.

Schuyler Lawson 35:15
Yes, to all our listeners, please get your shots. It's not just about you. It's also about everyone else as well. Please get vaccinated. So, I want to move on to the next question now for both of you. So, in your opinions, what are what are the biggest drivers of health disparities, and what would it take to eliminate these drivers? This is a very complex question. There's no simple answer, but I'd love your viewpoints.

Ebony White 35:50
What I would say is, education. Education around, these are the impacts of these chronic diseases, the impacts that they have on our community widespread, and how they are connected to our behavior. So, when I think about what is - Stan was talking about previously, they advertise more cigarettes, they advertise more alcohol in our community. What are we messaging? If you're the consumer, we have to understand, if you're the consumer and someone wants to sell something to you, you have to change what your desires are, what you want. So, we have to really get into our thoughts, process how we value our sales and what our desires are for our lives that we can change what is happening on the outside, what is being offered to us. If I say I don't want chicken, I don't want a bunch of cigarettes, the person that wants to come in, they have to dig a little bit deeper and find out what is in fact that they're trying to sell me, and what I want. So really, I think that education widespread, spending that that time, building that trust in our community, apologizing for stuff that you may not have done. You may have apologized for some things, but still standing, not running away from the pressure of the complexity of everything. People always have a lot of complaints, but we really strive to be solution focused. I hear you. I heard you acknowledge it. And how can we change this? So really, for me is education and more education. And it's going to take time. It's going to take a little time to change overall everything and finally eliminate it. So we have to change the minds of our community.

Stan Martin 37:52
Thank you, Ebony, I agree with you. And I would add the elimination of poverty. That's lofty. That's my vision though. I think that's the vision of a shared vision of others as well. To eliminate poverty, if we eliminate poverty, then really the essence of when we talk about where you live, where you work, where you play. And even pray and learn, then every child, every adult, every person has the opportunity to reach their fullest potential, their fullest ability, whatever that means to that person. In addition to that, I think that we have to address using the same cultural principles. We have to address racism in this country, the racial justice or injustices that have happened. We have to move from addressing that to really a point of being anti-racist. We have to dismantle systemic institutional racism. That really appears in every aspect of the work that we do, and until we do those things, I think that we will continuously revisit those things in one shape, form, fashion or another. And I think that really also we're in a climate of social justice and unrest. And a lot of that is due to not focusing on being equal, but we need to focus on equity. Equity is the denominator or the lens that we should look at promoting health and wellness from. To address it at every level, when you look at those social, ecological, at the philosophical, but at the individual level, the community level, at systems and policy changes and not have policies just exists on paper. What is having to come to reality to actually change to being a social norm? Like I say, it becomes our way of life in a healthy way. Thank you for the question.

Schuyler Lawson 40:15
Thank you both for your thoughtful responses. Very much appreciate it. So now we're nearing the end of the podcast. So, my last question is, is there anything else you'd like our listeners to know?

Ebony White 40:30
Get your flu vaccination. Again, I'm going to repeat it, do it for yourself, do it for your family and do it for your community, and continue to wear your mask. Practice social distancing. I know you miss all your friends, but please, let's not do that. Let's take care of each other, just for this period of time. And I'm hopeful that we'll get through this, but we want to make sure we're doing everything that we possibly can. Good handwashing, social distancing, wear your mask. If you don't have your flu vaccination, they are available. Stan will provide you with the website to get a flu shot. They're in your local pharmacies. If you have a primary care doctor. If you don't have a primary care doctor, please get one. Go have your flu shot this year and take care of each other.

Stan Martin 41:20
Yes, definitely. I echo Ebony's sentiments. Get a flu shot. If you don't know where to go, you can, if you have access to the Internet, you can go to GetMyFluShot.org, and then you put in your zip code and they'll give you information on where you can go locally, at your supermarket, at your pharmacies, or at different clinics in your area to obtain the vaccination. Thank you, Schuyler, for the opportunity to share this information with you and your audience.

Schuyler Lawson 41:57
You're very welcome. Again, thank you both for coming on onboard and be willing to be interviewed. I hope this reaches a wide array of our listeners. Thanks again to you both for taking the time to be on our podcast. We hope to have you on again to discuss future projects or ongoing projects to see how things are going. And listeners...

Stan Martin 42:25  
I’m sorry. GetMyFluShot.org, not dot com. I stand corrected.

Schuyler Lawson 42:34
GetMyFluShot.org. Thank you for the correction. And listeners, if you're interested in learning more about CAI and the great work that they do, visit CAIGlobal.org. Ebony, is there a website that the listeners could visit to learn more about the African-American Health Equity Task Force?

Ebony White 42:54
I would just direct them directly to CAI. Thank you.

Schuyler Lawson 42:57
You're welcome. I'm Schuyler Lawson, and thanks for listening to another episode of Buffalo HealthCast. Take care and be well.

Outro 43:09
This has been another episode of Buffalo HealthCast. Tune in next time to hear more about health equity here in Buffalo, the US, and around the globe.

All content © 2022 Buffalo HealthCast.

Intro: Hello and welcome to Buffalo HealthCast, a podcast by students, faculty and staff of the University at Buffalo School of Public Health and Health Professions. We are your co-hosts, Tia Palermo, Jessica Kruger, and Schuyler Lawson. In this podcast, we cover topics related to health equity here in Buffalo, around the U.S. and globally. In this first semester of the podcast, we're taking a deeper look at racism and health. We'll be talking to experts around the U.S. as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population health and well-being. You'll hear from practitioners, researchers, students and faculty from other universities who have made positive changes to improve health, equity and inclusion.

Tia Palermo: Okay, hello and welcome to our SPHHP podcast. I'm here with Adia Harvey Wingfield, Associate Dean for Faculty Development and Professor of Sociology at Washington University in St. Louis. Adia, I'm delighted to be speaking with you today 

Adia Harvey Wingfield: Thank you for having me. I'm happy to be here.

Tia Palermo: This year we've launched a new podcast for the University at Buffalo School of Public Health and Health Professions, or SPHHP. In the first year of the podcast, we are broadly focusing on the topic of racism and health. And today I want to talk to you about one aspect of racism in academia: the hiring of faculty.

You were recently involved in hiring several faculty members for a new Department of Sociology at Washington University in St. Louis, an effort that you detailed in your article in the Harvard Business Review, which was entitled ‘We Built a Diverse Academic Department in 5 Years. Here’s How.’ Can you tell me a little about these efforts? 

Adia Harvey Wingfield: Sure. So, I should say that when I came to Washington University in 2015, I was actually hired as part of a small cohort that was tasked with building the sociology department from the ground up. The university did not have a department prior to my arrival with my two senior colleagues, and our job primarily was to change that pretty much, and to do the work of making sure that the department grew into a top sociology department.

And one of our shared goals early on in those stages was that we really wanted to be indicative of the fact that departments can be really strong academically. They can do a great job focusing on research and teaching, but they also can do so in a way that prioritizes both excellence and racial diversity, and that contrary to what some might think, it's not impossible at all to meet both of those goals and to set those standards.

So, our focus was on making sure that we certainly built an outstanding department, but that we did so with an eye towards what it would mean to be a racially diverse department in the university and in the discipline. And that's driven a lot of our focal points on hiring and outreach and building over the last five years.

Tia Palermo: That's great. Thank you. So how did your own research background - examining how and why racial and gender inequality persist in professional occupations - inform these efforts in building this department of sociology?

Adia Harvey Wingfield: That's a great question. I would certainly say that my own research gave me some insights into the types of pitfalls and challenges that many workers of color encounter when they are in spaces where they're in the racial and/or gender minority. I know a lot about that experience from the work that I've done in identifying what those challenges look like and some of the processes that workplaces and organizations engage in that can be unwelcoming or hostile to communities of color.

But I have to say that it wasn't really so much an issue of building from my own research as much as it was working collaboratively with my departmental colleagues and university administration, all of whom were very supportive and enthusiastic and shared this goal of wanting to make sure that we did have a racially diverse department. It was very much a team effort at a variety of levels, which is really critical and important for being able to achieve these goals.

Tia Palermo: When you and colleagues decided that you wanted the new hires to be racially diverse, did you face any pushback? So, you talked about how you had support at multiple levels, but was there pushback from any corners and how did you overcome this?

Adia Harvey Wingfield: Again, luckily we all were of the same mindset and the fact that we believe that racial diversity and really working to achieve it was important. So, there were not issues internally around why this mattered or if we could do it or if it was something that we really wanted to focus on, or, again, this false dichotomy between diversity and quality. None of that was an issue at a department level, and certainly it was not an issue at the administrative level either. We're really very fortunate that we were very clearly supported in this goal by the administration and the workers that we dealt with that level, the dean, the provost, the chancellor at the time, were all very much on board with this being an important factor for us, which is part of why I write in the article that for these types of initiatives to succeed, I believe it's really critical to have support from multiple levels of leadership.

I think it would have been a lot more difficult for us to achieve the diversity that we did, if I were a lone voice with making this argument in a department with colleagues who did not share this principle. Similarly, I think it would have been very difficult for us to achieve the outcomes that we did if, as a department, we had to face a lot of headwind from the administration, if we were working with leaders who did not share our commitment to these values and see this as important. I think that my experience shows that the synergy along those lines indicates that change certainly is enabled when it comes from the top, but that that change also has to have buy-in at, what you might think of as middle management levels as well. But when you do have those synergies lining up, it really opens up a lot of potential doors and opportunities for what you're able to build and accomplish. 

Tia Palermo: Thank you. When you were going through the hiring process, what efforts did you make for the candidates when they were visiting? Both so that they would feel that Washington University in St. Louis was a welcoming environment for them, and then once you hired candidates, how did you make them feel welcomed and supported once they arrived on campus as new hires?

Adia Harvey Wingfield: Yeah, that's a great question. So, when going through the interview process, I think it's really critical to make sure that people get a feel for what their experience on that campus will be like, should they decide to join the department. So, you have to make sure that people see that there are opportunities for them that relate to the things that they want to pursue. 

If you have a candidate who might, for instance, be interested in studying issues related to immigration, it's important to let that candidate know that not only rebuilding that in our department, but there are other people on campus that you might want to connect with who are doing this kind of work. We're talking about attracting faculty of color. It's critical for faculty of color to see that they won't be alone, isolated or excluded in everyday campus interactions and deliberations. 

So I think it's really key to make sure that when you are trying to recruit underrepresented minority faculty, it's important to make sure that they see other people on the faculty and that they have a chance to talk openly and candidly and privately with them about what their experience has been like, rather than having simply people tell them, "This is a great place for scholars of color," and "People are really happy." That doesn't carry as much weight unless you hear it from the scholars of color in question who can tell you again in a private setting where they can speak honestly whether or not that's actually true. So when we were recruiting candidates, we made sure to try to show them that there were links between their personal and professional identities, that the university recognized, respected and wanted to support so that if they accept an offer and they joined us in the university community, they would have a view from their interview with what that experience would look like for them up front.

When it comes to people actually being here, I think if you want to build on the groundwork that you've laid through the interview process to make sure that once people have accepted the offer, you can't then pull a bait and switch and have them in an environment where they and their work are not supportive and are not respected or treated equitably and fairly. So, we a pretty robust mentoring program in our department to make sure that everyone has access to mentors and support and people who can guide their careers, particularly for assistant professors who are going through the tenure process. But we also make sure that assistant professors, particularly underrepresented minority faculty, continue to remain aware of and feel connected to the life of the university, whether, again, those are through initiatives and groups that speak to their personal identification and/or things that speak to their professional research interests.

Tia Palermo: So, it sounds like you had a lot of support systems built in, in this department from the beginning. Do you have any examples of cross campus initiatives that help support those incoming candidates?

Adia Harvey Wingfield: Sure. Well, so our vice president provost for diversity and equity and inclusion actually runs a number of initiatives that are designed to reach out to all areas of the university and provide those kinds of supports. There are informal activities. There are more formal activities. There are monthly lunches for women faculty of the university to make sure there's a sense of camaraderie in cohort building. There are also leadership development seminars for faculty of color who may be interested in pursuing those types of initiatives there, and that's just in one office. So, there are a number of programs on campus that are in place to draw attention to the fact that if Wash U is going to be a place that does want to take seriously these imperatives of diversity and equity and inclusion, it's not enough simply to say that. That has to be matched with clear, robust directives that speak to acknowledging those issues, tackling them head on and making sure that the university is working to do all it can to support faculty who are underrepresented.

Tia Palermo: Thank you for that insight. Have you seen the success that your own department effort has had, influence other departments or initiatives university wide in their hiring practices?

Adia Harvey Wingfield: It's a little hard to measure just because there's so much variance across arts and sciences and there's so many different disciplines within that one college alone that there's a lot of range among them. But I will say that I think that the fact that we have been so successful and done so well in building a racially diverse, academically strong department in a short period of time has certainly been recognized in the university community. And I think serves as a clear message and indicator to other departments that, again, this is something that's possible to do with the right programing, plans, commitment, and initiatives in place. I will say that I do think that the work that we have done that functions to show that this is a step that that departments can take, to follow this lead.

Tia Palermo: That's great. And it really is an impressive group of scholars that you have in your department.

Adia Harvey Wingfield: Thank you.

Tia Palermo: You have a recent paper entitled ‘Getting In, Getting Hired, Getting Sideways Looks, Organizational Hierarchy and Perceptions of Racial Discrimination.’ The participants in that study were from the health care industry, not academia. But in this work, you demonstrated that position in the organizational hierarchy is linked to perceptions of racial discrimination, whereby individuals at the top of the hierarchy, some examples in that study where doctors, reported fewer individual incidents of racism but identified more structural and organizational discrimination as compared to individuals lower in the hierarchy. Examples of structural discrimination included the education pipeline, hiring decisions, and developing a mentoring relationship, something you spoke about earlier. What parallels can you draw between that study and implications in academia, given that academia is also vertically ranked in terms of students, professors and hierarchy among professors?

Adia Harvey Wingfield: So that's another great question. And I first want to offer the caveat that the study, as you mentioned, is focused exclusively on health care workers. So, I think that there likely are some parallels, but I don't want to give the impression that I'm speaking from data when I answered a question. I did not interview primarily academics. So, I cannot say with certainty that the patterns that I described among health care workers would necessarily be present among people in academia. But that said, I do think that it's at least likely to, I think it's safe to hypothesize that there may be some comparable outcomes and there might be some parallels, right? So by way of example, when we think about how academia is hierarchically organized and how it's very hierarchically structured and ordered in a lot of ways around similar ideas of status and prestige, I think that it may certainly be the case that for faculty, the experiences that they cite with how race has an impact on their work may certainly be more likely to include more structural processes as well as the more interpersonal ones, which was what I found with actors in my study.

They cited that there were some cases when they had interpersonal experiences with racial discrimination. But as you mentioned, by and large, what stood out for them were the structural barriers that made it difficult to advance into and thrive in medicine and in physician work in particular. I think it's not difficult to speculate that similar processes might be true for Black faculty and certainly for Black administrators in ways that I think might reflect different outcomes. If we're talking about black employees of a university who are in staff positions, particularly if they maybe a lower level staff positions that don't offer the same autonomy or status or ability to shape one's work environment.

That, I think, is certainly true for professors. So, I think that there are likely some comparable outcomes that we would see between academia and the health care industry. Even though the study didn't focus on those fields, I think it's safe to guess at least, and hypothesize that the higher one is positioned in the organizational hierarchy, the more impact that may have on perceptions of racial discrimination in academia as well. But that's a question for maybe a future graduate student to just study a little bit further and to see if my hypothesis is correct.

Tia Palermo: That's great. We're exploring ideas for future research here. Thank you. Can you say anything about the resistance to hiring more than one underrepresented minority in a department or what's sometimes termed as the ‘only one’ syndrome? Have you seen this played out?

Adia Harvey Wingfield: Fortunately, in my current department, that's not an issue that we have. Like I said, we've worked hard to make sure that we do have a racially diverse department, both among our top ranks of faculty who are full professors, and that that continues throughout the department as well at the untenured ranks as well. But I will say that this experience of being the only one or organizations that seem to feel as though hiring one person at a high level ranking is sufficient and gets the job done, is not only something that exists, but something that is inaccurate in terms of the ability to really diversify an organization or a level of an organization.

Research indicates pretty clearly and conclusively that when workers are white women or people of color, and they are underrepresented in positions to the point where they are the only or one of very few at that organizational level, they are a lot more likely to be mistrustful of the organization's commitment to equity and equal opportunity. They are, if they are women, more likely to experience sexual harassment, they are more likely to consider leaving and they are less likely to be satisfied with their employment in that company.

So, organizations in many cases may see this idea of this only hiring phenomena as progress. right? That we've got one person in our C suite, and we've done a great job because we've got one person at this executive level, so we can brush up our hands and say we've solved that diversity problem. But again, that's short sighted and it's not correct. And it comes with creating an environment where in the short term, you may be able to say that you have this one person filling this role, but that one person's experiences are likely more challenging than they would be if they had a cohort experience of more robust representation. And if ultimately what that leads to is that person not producing as well as expected, or that person looking for other opportunities, or that person being disengaged from the organization. The organization is not really winning if they're not maximizing and making full use of that person's talents and opportunities.

Tia Palermo: That's a really great summary of how the challenges that the individuals can face, but also how those challenges can play out in adverse ways for the organization as well. What would your response be to people or departments who say we've tried to diversify our hiring, but qualified scholars of color either aren't accepting our offers or they have too many offers to choose from. They don't want to come here.

Adia Harvey Wingfield: One wants to know what exactly trying to diversify your hiring looks like. Does that mean making an offer to one person? And then if and when that one person declines, not trying again? Does it mean trying to hire someone that you know is already in demand from other places who has multiple other options, and then saying, well, we made an effort, but this person just doesn't want to be here. These people don't want to be here. There not much more that we can do. Does it look like that?

If that's the case, I would not really find that to be such a compelling argument. I'll put it that way, right? I mean, we know if we look at data that there, in most cases, research indicates, are more candidates of color available for positions than there are actually positions. So given that mismatch, it's not that we see the glut on the supply side, right. The issue is not that we see the narrowing on the supply side, more so on the demand side. And if that is the mismatch, then it strikes me that most departments, if they really have the will, if they really have the interest, if they really want to put the work into finding really strong candidates of color, this this is achievable. And I think that my department and the success that we've had indicates that this is achievable, right?

But it may mean not simply going back to your networks of people that you already know and looking for candidates through them. It might mean looking for candidates through other networks that are specifically inclusive of and designed to include candidates of color. It may mean reaching out to people and explicitly saying that you really want to have a racially diverse applicant pool and asking your connections and your networks to make sure that they mentioned that you have an available job and encouraging candidates of color that they may be advising to apply for this position on top of the accessing listservs and professional organizations and things like that, that are more racially diverse.

Those might be critical steps that organizations have to take when it comes to hiring. But I believe that doing so really has implications for what the applicant pool looks like. I'll also say that taking those first steps should not be the sum total of what those efforts to racially diversify looks like, because if organizations take those early steps and build an early pool of candidates that are racially diverse, but then as we go through the whittling process, somehow it just happens that you happen to whittle out all the candidates of color. You want to be a little bit more reflexive at that middle stage about what you're a long, short list is looking like, or what your fly out list is looking like, or whatever you want to term it. So, I would say that I don't really think in this day and age when organizations or departments say that they've tried, but they are simply unable to hire candidates of color. That makes me wonder what processes they are using to engage in hiring, because it makes me suspect that perhaps it's those processes that are returning a dearth of strong candidates of color, more so than a lack of strong candidates of color really being out there.

Tia Palermo: There's some really great recommendations in there about directly reaching out and exploring new networks, and making sure that the early steps in the process are not just where it ends. So those are really great suggestions. Thank you. What advice do you have for departments? Probably some similar advice along those lines, but advice for departments who are aiming to diversify but perhaps can't do so as rapidly on the scale that your department did?

Adia Harvey Wingfield: So that's a great question. And one thing to acknowledge about our department is, like I said, when I started, we were brand new, we knew that we had to build. We had support for from our administration for doing a lot of hiring in a short period of time because we had to. And I obviously recognize that every department is not going to be in a position where they are granted 10 hires in the state of three years. I think most departments are not going to be in that position. Again, that said, that does not necessarily mean that it's impossible to achieve these goals. And the fact that our department had these hires didn't necessarily automatically translate into making sure that our hiring process would turn out to be racially diverse. That didn't happen just because we had hires. That happened because as a department, we made an explicit, intentional commitment to making sure that that was the outcome and that that commitment was supported by administration. Had we not had that commitment and had administration not been supportive of it, we could have very easily not had a racially diverse department. I could have not written that article at all because there wouldn't have been anything to talk about. So, I say that to make the point that most departments are not going to be in a position where they're doing that much hiring that quickly.

However, I recognize that we're in a pretty difficult situation now for many universities where budgets are lean and positions may be cut, but knock on wood, eventually we've got to get to another side where universities and departments do begin hiring again. When we do get to that point, I think that any department is in a position where they can follow these steps. Think about how you are initially seeking candidates for open positions in your departments. Are you simply posting an ad on a list serv and waiting for people to come to you? Or are you actively trying to cast a wide net so that you can attract candidates of color to want to apply to your department? Once you are going through the applications that you have, are you doing so with an eye towards making sure that you are not somehow systematically weeding out candidates of color from those who make the initial applicant list to those who make the long shortlist? Are you doing the same thing when it comes to your fly out list? When you do bring in candidates, if you do bring in candidates of color, are you making sure that on the campus visit you are not creating an experience that is alienating? Are you making sure that they have access to or have a window into what their experience of campus life would look like, were they to be hired? And if you ask yourself that question and the answer is that the window of what campus life would look like for a candidate of color is campus life would be pretty bleak, that's a point to some bigger issues that could be useful to reconcile. What would it take to make your university campus one that is approachable and welcoming and inclusive of a variety of candidates of color? If that's something that is a sticking point at that point, it's useful, I think, to have a bigger conversation to raise these bigger questions of how the university at large may want to change, to be a place that is more attuned to the importance and need for more racial diversity on campus.

Tia Palermo: Thank you for that. So, we've been talking a lot about the hiring side. But let's flip it. And do you have any advice that mentors and advisors should give their underrepresented minority PhD students, when they're going on the job market in terms of finding an environment that's a good fit?

Adia Harvey Wingfield: That's a great question. Again, I think that it's useful to look at the experiences that faculty in a place already have a place. Right. So, if you are a mentor or an adviser to a person of color who's going on the job market, I think it's useful to encourage them, and they may already be thinking this, but I think it's useful to encourage them to get a sense of what life in that department and in that university would be like. If they are applying to departments where the department in question hasn't tenured any faculty of color. Are they applying to a department where the department in question hasn't ever hired any faculty of color? Those are things that are going to matter, and those are things that the faculty of color have to navigate when making employment decisions and weighing particular options.

So, I would encourage mentors and advisors to make sure that they are assisting their advisees in doing the legwork of finding out what the general climate and experience for them is going to be like. You don't want, in my view, simply to say that you want to send someone to a top rate program in whatever field if being in that environment is going to be miserable for that person. In my view, that is simply not worth it. Other people may think differently and probably do think differently. But I think that that's not a fair trade off to ask junior faculty of color to make when they are looking for employment.

So I think it's important for advisers to make sure that they take into consideration that advisers of color have a relatively unique experience and that they consider what the entirety of department and university life will be like for them as people of color in these settings, and to make sure that that is a factor that they weigh in determining whether to apply for positions and ultimately whether to accept.

Tia Palermo: Some really great advice for advisors and PhD students on the market.
This has been really insightful. Is there anything else that you'd like to share with our listeners about the topics or related topics that we've been talking about?

Adia Harvey Wingfield: I believe I would just add that I think this is really a critical moment for universities right now for a lot of reasons. We are seeing the ongoing protests for more racial equity and an end to systemic racism in society right now. We are at a point where the nation is becoming increasingly multiracial. Students of color are growing numbers of those who are attending universities. The numbers of faculty of color have not necessarily shifted in commensurate ways. 

And this presents a real problem that I think universities need to devote some time and energy and effort into tackling. That kind of mismatch, in my view, does not bode well for outcomes for students. But not only that, it doesn't necessarily bode well for universities as we continue to move into the 21st century and becoming a more racially, more multiracial society. I believe that universities will be largely better equipped to come to terms with those demographic changes if they actually reflect those demographic changes. So, I think it's really critical to grapple with these questions of how best to do that in ways that make sure that both students and faculty are adequately represented and completely included in environments that have a long history of being very exclusive and unwelcoming and alienating and hostile.

Tia Palermo: Adia, this has been so insightful and really a pleasure to speak with you. I really just want to thank you for sharing your insights with me and with our listeners here at SPHHP. It's been really great to talk to you. Thank you.

Adia Harvey Wingfield: Thank you for having me. I'm happy to do it.

Outro: This has been another episode of Buffalo HealthCast. Tune in next time to hear more about health equity in Buffalo, the US, and around the globe.

Intro: Hello, and welcome to Buffalo HealthCast, a podcast by students, faculty, and staff of the University at Buffalo's School of Public Health and Health Professions. We are your cohosts Tia Palermo, Jessica Kruger, and Schuyler Lawson. In this podcast, we cover topics related to health equity here in Buffalo, around the US, and globally. In this first semester of the podcast, we’re taking a deeper look at racism and health. We’ll be talking to experts around the US, as well as individuals here on campus, and in the Buffalo community who are working to remove inequities and improve population health and well-being. You’ll hear from practitioners, researchers, students, and faculty from other universities, who have made positive changes to improve health equity and inclusion.

Jessica Kruger: Welcome to the Buffalo HealthCast. I'm your host today, Jessica Kruger, and I'm joined by one of our amazing three plus two students in the Department of Community Health and Health Behavior, Temara Cross. Temara, will you tell us about yourself?

Temara Cross: Sure. So hi, everyone. My name is Temara as she said, I'm currently in my first year of the CHHB program. I'm also pursuing a Bachelor's in African American Studies. I was born and raised in Buffalo, involved in several social action organizations in Buffalo, and in my "free time", I say with air quotes, I enjoy giving back to my community singing with the gospel choir at UB, going to church, and also playing basketball. So that's a little about me.

Jessica Kruger: Fantastic. Well, thanks so much for joining us. I'm really interested in learning more about your internship that you're currently in with REACH Buffalo. Could you tell us about your role in that internship and a little bit more about REACH?

Temara Cross: Sure, yeah. So, REACH Buffalo stands for Racial and Ethnic Approaches to Community Health, and this initiative is funded by the CDC. We're in year three now, and the primary goal is to reduce chronic disease in our target population, our priority population, which is our residents along of Ferry Street, which is East Ferry and West Ferry, and also, we try to focus on five zip codes which is 14208, 14209, 14211, 14213 and, 14215. So that's our primary goal and we make sure that whatever programs that we implement, we make sure that we have community voice. So, we have community wellness champions, and then just several people on the team just working together, but my specific role is a REACH program Intern/Assistant. So, I'm helping out on various projects, not just one focus area. We have different focus areas, by the way. One is Community Clinical Linkages, another one is Nutrition, and another one's Tobacco. So, we focus on all of them. And we also received a supplemental grant this year because of COVID, of course, but our main goal is to promote and educate the community about the flu vaccine and just making sure the community knows that they had the opportunity to take it, and yeah so, that's what I'm doing.

Jessica Kruger: Sounds like a really exciting project and group to be part of. Could you give us an example of maybe something specifically that you've worked on with the program?

Temara Cross: Sure, I'll talk about how I hit the ground running. So, I started in August of this year, and soon as I got my laptop, they were like, alright so Black Breastfeeding Week is coming up in two weeks. So, we want to start some programming, but obviously we had restrictions because of COVID, so we did stuff virtually. We broadcasted Chocolate Milk, which is a documentary about black women who breastfeed. We did that, we had a discussion/forum about partners, how they feel when they're supporting mothers who breastfeed. We just had discussions about black mothers who breastfeed and how they felt about that. All virtual.  

Jessica Kruger: Wow, sounds like a huge undertaking that you definitely rose to the challenge for. In your internship, what are the most valuable things that you feel like you've learned so far?

Temara Cross: That's a great question. I would say the most valuable thing I've learned in practice, I would say, is really actually appreciating community voice, because we might have X amount of years in a community, we might live there, we might know someone who lives there. We might have been in the field for so long, but if you aren't living and going through certain things, you really don't know how other people perceive what you might think is the best for them, so I've just really learned to appreciate community voice and really use that as community assessment. Really taking that - not just checking off a box like, okay, we listened to the community, but we're still going to do XYZ. No, really taking that into consideration. That was something that I found really valuable and really helpful because again, they don't even have to be taking their time out to help us mitigate chronic diseases in that area, but they're still contributing, and we appreciate them for it.

Jessica Kruger: That's a really important part of public health that sometimes often, like you said, as a checkmark, right? But we really, really need to think about who we're serving and how we serve them. I heard a quote; “Not about us without us.” Right? And that has really stuck with me and how you work with the community, and work with the community, not just for a community.

Temara Cross: Exactly.

Jessica Kruger: So, thanks so much for telling us about your internship. But I want to know more about you. In particular, you have a really interesting background in some of the areas that you have studied. So, you're a major in African American Studies, and you minor in Anthropology. Can you tell us a little bit about why you have chosen those, and how they flow into your work in public health?

Temara Cross: Of course. I'll start right back to 16-year-old me, junior year of high school. I knew I was going to be a teacher of some sort. Didn't know what, but I was just going along at Hutch Tech. That's where I went to high school, here in Buffalo. We had majors in high school, like certain concentrations. I was in biochemistry, and I was like, I don't know what I'm going to do, but I'm going to do something and it's going to be teaching, and November comes around and I find out my grandmother's really, really sick. She had kidney failure, and congestive heart failure. So, I'm like, what is going on? Before she was able to speak with us anymore, I was asking her, "Why didn't you take action sooner Grandma? Why weren't you talking with the doctors, really doing what you had to do?" She was, obviously, but she really stressed the fact that she was tired of seeing other doctors, all different doctors, all the time, because she had different organ systems, which require different doctors. So, she was tired of seeing different doctors, and then she had to keep explaining her story to different doctors. So, there's that. And then not seeing doctors who looked like her. And that was really the big thing that stuck with me. The distrust that we see in the medical industry, that was just really my firsthand, wow, this really exists. So, after she passed away, I was like, is this really recurrent like in my community? Is it just her? So, as I'm observing, asking my community members, asking my neighbors, asking my family, my immediate family; how do you guys feel about going to the doctor? And they're like, we don't go there unless we absolutely have to. We don't go, we're not we're not speaking to "these people", but again, that's when I realized the best way I could serve my community, because I'm always very community oriented. But the best way I could, was to serve in the health industry, in the medical field. So, I decided that I would pursue medicine eventually, and then launch a health facility on the east side of Buffalo.

So with that, to kind of reel it all in, I'm majoring an African American Studies, just to gain more a historical and better understanding of why, because we're not learning that, and that's another thing - we're not learning that in our general education courses. We know it's briefly talked about, but we're not learning about Tuskegee as much as we should be, we're not learning about Samuel Cartwright - all these people who have used Black bodies for the advancement of medicine. We're not talking about that as much as we should be. So that's why I decided to major in African American Studies, and then with Anthropology, I just wanted to pick something up to learn more about why people do what they do, as far as culture. I've had the opportunity to go to a more diverse high school, so I was exposed to different cultures, but not really understanding why people do what they do - how cultures are formed and things like that. So that's why I decided to just minor in Anthropology, get the best of my money's worth.

Jessica Kruger: That's such a moving story that how you took a very traumatic event in your life and turning it into something positive. I'm right there with you. I also have a minor in anthropology for my undergrad and I think it's pivotal to begin to understand the perspectives of others and how that's created, and you bring up a really good point about the culture, the historical relevance of events that we really need to integrate into our curriculum. And think about, we can't move forward, if we don't understand the injustices that have occurred in the past. Do you have any advice of how we can begin to make some of those changes?

Temara Cross: I'm not going to speak too much, can't spill all the tea, but I'll say Black Council is in the works of really redeveloping and redesigning the undergraduate curriculum, just to kind of expose people - to have a course where not only, of course, but also make sure this is a design where it's throughout all courses, but really understanding how to be antiracist because I know from personal experience, a lot of my friends from Williamsville, Orchard Park, they have never had to have those experiences and they have never had to have those conversations. So, coming to UB, we as Black Council and also personally, we believe that UB should be held accountable to provide courses like that and be able to put that into correct themselves required for students. Not, "Oh, I'm going to check this box for diversity because I took a class in diversity." And it's not like that. You don't have to experience it, but you have to have training of some sort, and you really need to be exposed to how to be antiracist because being complacent is just as bad as being racist.

Jessica Kruger: Wow, that's, that's a really important point that you're making. It's not just one class that changes you - it's being open to continually learning, being open to hearing diverse voices and viewpoints, and being uncomfortable. Some of this can be very uncomfortable to learn about, especially, we know that in the history books that you're taught through school, it's from a very white lens. And so how can we begin to change that? And I think you've come up with some really great ideas. So, tell us more about the Black Student Council.

Temara Cross: Right, I actually saw that you looked for it on UBLinked, and we're not on UBLinked yet. I don't know what we're doing, but the UB Black Council is a coalition, I would say, not a coalition, but it's comprised of all the black organizations at UB, so we have Black Student Union, Caribbean Student Association, African Student Association, UB Gospel Choir representative of that organization. So many of us, but we came together. It all started back in 2019 February, where there was a town hall meeting, we were really upset about the budget cuts to organizations that really aim to ensure Black student success. So Educational Opportunity Program, C-Step, and there was a town hall, and we had a rally, and we were like, you know what, since all of us think alike, why don't we just come together? Because we have all these different black organizations, but we all feel the same way. So, we came together and wrote a couple proposals, wrote a couple demands, and we just hit the ground running from there. And as people graduate, as people and move on and start adulting, we have to pass the torch and stuff. So, our main goal right now is sustainability of the Council, and making sure that we continue to increase the momentum and push the administration at UB - just making sure that we keep that going. Despite having online classes in these unprecedented times, it's really hard for us to come together, but when we do, we're trying to make sure we really hit the ground running and hold UB accountable for ensuring black student success. A few of the things I'll just mention.

So, one of the things we are really looking forward to making sure UB addresses is increasing the minority admission or acceptance rate. And one thing that resonated with me when I read that demand was how - so I serve on the Say Yes council/committee at UB. We just ensure the students at UB who received a Say Yes scholarship or are a Say Yes student, so they don't have to get the scholarship, but they graduated from a Buffalo Charter or public school. So, our goal is just to make sure that they have the resources they need at UB, and one thing I learned was that the admissions at UB goes to certain high schools. They don't go to all the high schools in Buffalo. And looking back, this is why sometimes, I just wish I knew all these things when I was in high school, but you learn as you grow, and as you get older. But they only go to Hutch Tech - the high-performing high schools - City Honors, Da Vinci... And it just goes to show you, the students in the other high schools aren't even given the opportunity of exploring what's out there, of not just the other local colleges. This is university and for them not to do that alone, is really systematic. It's a systematic and it's really something we wanted to address because the population of black students at UB is so small, the proportion is so small. So, we want to just hold UB accountable, such that they really strategically seek out other students of color to have the opportunity to obtain a degree there.

We're also looking at increasing Black faculty. We know that while Black faculty are recruited and they come along, a lot of times they leave because of the climate of the institution. So that's one thing that we feel like they should address. Again, another thing I'll mention is the curriculum development; really making sure that it's not just one class that addresses racism and discrimination, but it’s implemented throughout all fields, especially STEM fields. One of our members, she shared a really touching story about how she came in and her advisors really were discouraging her from taking African American Studies courses because you don't have space for that, and I'll attest to that because I came in as biomedical sciences, and it was a really rigid curriculum. I couldn't take what I wanted to take, so those are just a few of the things that we want to address. We're finding out as we go along that a lot of people think the same way we do, so there's power in numbers, as we know, democracy. So, we're just working together, working, finding the connections where we can, but we always need support. So if there's any students up there, any organizations that want to get involved, Black students - you can hit us up on Instagram, Twitter, @UB Black Council. I'm just promoting here. UBBlackCouncil@gmail.com you can hit us up and find out ways you can get involved. We're just trying to really hold UB accountable especially given the climate now. And I always say this, and I'll continue to say it; it's unfortunate that it took the death of a man for the country to realize how oppressed black people have been for over 400 years, but it's time. With that, I'll stop, I'll get off my soapbox but that's what we're doing.

Jessica Kruger: Well, it sounds like you're using a lot of your public health skills to organize and break down some of these systems. It's really powerful to hear how much you're doing as a student. You want to kind of tell us a little bit about how your work with the Black Student Council relates to your overall public health lens or how you kind of view things?

Temara Cross: Oh yes, I'll just say, every week going through, even in undergrad, every week I'm just finding how public health is my life. I won't speak for anyone else but like how public health is every day is something. I think it was last week, we learned about negotiation in one of our leadership courses in the in the CHHP (Community Health and Health Behavior) program and I was like, this is really applicable to my life, it’s not just public health. And they gave us examples of how negotiation is used in public health - negotiating with a state about funding for vaccines, stuff like that. And I'm like, well, you know, we have to negotiate on a daily basis. So, it's not just from a public health lens, and I'll say my internship with REACH, I'm literally taking what I learned in the class. I know this is the purpose, but it's like I'm scooping what I learned in the class and putting it right in the internship and it's vice versa. I'm taking what I learned the internship and really applying it with the coursework and I'm so grateful. I'll shout out to Heather Orom; she was the one that emailed me and was like, this is for you. So, I thank her for that.

But yeah, it's really just so applicable and I'll just go back to the Black Council on the negotiation. That's just one primary example, really negotiating such that administration - I'm grateful for what UB administration has done thus far, for some things I'll say. That's a long way to go. But again, it has to be negotiation, it has to be communication, consistent discussions and yes, so that's just one thing that I've learned primarily in my program that I was able to like directly apply, but there's so, so much, so much.

Jessica Kruger: It's so great to hear, it sounds like you're really taking what you learned and applying it exactly as you know an internship is planned and I love how you can really translate this into multiple areas of your life, not just your internship or your professional career, but also how you're taking some problems that are very apparent of the university and using those skills and knowledge to make some of that change. So, bravo to you!

Temara Cross: Thank you.

Jessica Kruger: Tell me what's next.

Temara Cross: Oh, man. You know what's crazy is I have all these post-it notes on my wall. And I said, I am never put any post-it notes, that's so disorganized, but every idea that pops in my head, I just put it on my wall, and eventually I want to go to med school. And I was like, do I take a gap year? What do I do? Because this semester alone was really, how can I study for the MCAT, with all this going on?

But I was thinking, okay, maybe I'll take my break, considering we have an extended break, take my break to study for the MCAT. So, I guess, next, aside from actually finishing my master's program, I'll be starting to look at med schools. And I don't want to leave Buffalo, but I'm a homebody but exploring other options, I'll say. So that's what I'll be doing. I'm just chugging along with my social action organizations - Open Buffalo, Buffalo Transit Riders United, and obviously being a student too. But yeah, really, just chugging along but also taking days to myself. Like I said, I'll be eating a lot tomorrow with Thanksgiving. I'll be eating so much, but yeah, making sure my cup is full. I'll say that. That's my primary next step is making sure that my cup is full. So, I can do what I want to do and give back to others.

Jessica Kruger: And self-care is so important in our field. Well, I can't wait to see all that you accomplish in your program. So, thank you so much for being a guest on Buffalo HealthCast today. I'm sure all of our listeners have learned so much about REACH, but also some opportunities in which we can make change and support students and making change.

Temara Cross: Of course, of course. And if you guys have any questions, feel free to email me temaracr@buffalo.edu, find me on Facebook, I post memes mainly, keeps me sane.

Jessica Kruger: We'll put the contact information in our show notes. Thanks so much for tuning in.

Temara Cross: Of course.

Outro: This has been another episode of Buffalo HealthCast, tune in next time to hear more about health equity in Buffalo, the US, and around the globe.

Intro  0:00 
Hello and welcome to Buffalo HealthCast a podcast by students, faculty and staff of the University at Buffalo's School of Public Health and Health Professions. We are your co-hosts Tia Palermo, Jessica Kruger, and Schuyler Lawson, and in this podcast, we cover topics related to health equity here in Buffalo, around the US and globally. In this first semester of the podcast, we're taking a deeper look at racism and health. We'll be talking to experts around the US, as well as individuals here on campus and in the Buffalo community who are working to remove inequities to improve population health and wellbeing. You'll hear from practitioners, researchers, students and faculty from other universities who have made positive changes to improve health equity and inclusion.

Schuyler Lawson  0:47 
Hello, everyone, and welcome to another episode of Buffalo HealthCast. I'm your host, Schuyler Lawson, a first year PhD candidate in Community Health and Health Behavior. With us today is Reverend George Nicholas, a co-convener of the African American Health Equity Task Force, and a member of the Concerned Clergy Coalition of Western New York. Thank you for taking the time to be interviewed with us today.

Reverend George Nicholas  1:10 
Well, it's certainly an honor and a great opportunity to be with you today.

Schuyler Lawson  1:15 
Great. So first off, can you, for our listeners, can you tell us a little bit about yourself?

Reverend George Nicholas  1:21 
Yeah, I'm from Buffalo. This is my my home. I grew up here. Then went to Ohio State University for undergraduate and then came back to the area. I have a graduate degree from the University of Buffalo, and had been working doing various jobs and doing things. I've owned companies. I was a CEO of Geneva B. Scruggs Community Health Center at the time, and then I decided to answer the call that the Lord put on my life many years ago to go into ministry full time. And I did that and was pastoring Rochester for about 12 years. And then the Lord called me back to Buffalo and I've been back here since about 2012.

Schuyler Lawson  2:12 
Yeah, a lot of history in Buffalo.

Reverend George Nicholas  2:14 
Yeah. Oh, yeah. Yeah, this is home and I've seen the ups and the downs. And I think we have an opportunity to really do something transformative right now. And it's necessary because I've seen how Black Buffalo really hasn't progressed. Some of the things, that in terms of, we have less businesses now. We have less community based organizations. I mean, we're so vulnerable. I mean, we used to have the Geneva B. Scruggs Community Health Center, which was a community health center that served this community. We had the St. Augustine Center, which was a tremendous community based organization on Fillmore Avenue, they're no longer there. The Langston Hughes Cultural Center, which was at 50 High Street, was a tremendous cultural center. Friends of the Elderly. There were a number of programs that were run by black people, and that addressed the needs of black people. And over time, these things have not been supported by the existing political establishment and they've gone away. Certainly, on the business side, we had tons of of cleaners and restaurants and all kinds of things; Jefferson Avenue, Fillmore Avenue, parts of Genesee, they were bustling with black-owned and operated companies. And then finally, and I know we're gonna get to these questions, but I think it's important to put things in a context. I'm 57, and when we were coming up in the area, the notion of black kids not graduating from high school wasn't even a conversation. You graduated from high school. But now, we have folks struggling just to graduate from high school. And then even as they matriculate on to the campuses at the University of Buffalo, there's probably less black students from Buffalo there now than there was 15-20 years ago. And so we got to turn this thing around Schuyler. We are not going in the right direction. And so we will talk about that a little bit later too if you want to. Leadership.

Schuyler Lawson  4:52 
I agree with you, and like you said, even though the current situation appears to be bleak, you did say that there is an opportunity for transformation and hopefully long lasting changes. Which is a great segue into the African American Health Equity Task Force, which appears to be a force for good, in respect to the issues that you mentioned.

Reverend George Nicholas  5:16 
Yeah, so we've been working really hard, it started off with a conversation with just a few of us. This woman named Mary Walls, at the time working, I think, for the Heart Association, or the Red Cross, one of those places, and she wanted to engage some Black Clergy in conversation about colorectal cancer. There's a disproportionate amount of black people who suffer from that. And so I challenged the group to think bigger, and to look at the overall health of Black Buffalo. The factors that were driving high colorectal cancers are the same factors that are driving diabetes, and heart disease, and asthma and all kinds of things, hypertension, and it's the social determinants of health, right? There has to be a shift between thinking about and looking at Black health and putting all the blame upon the behavior of people in the Black community. That old adage, "Well, y'all just eat too much fried foods," and all this other stuff. Well, that's part of the equation. But when you look at what the reputable organizations that deal with public health, the World Health Organization, the Center for Disease Control, the National Institute of Health, and every reputable organization that focuses on public health, will tell you that the driving factor, the most influential factor, that impacts the health of an individual, are the social determinants of health. The lived environment, the economic status, educational attainment, interfacing with the criminal justice system, the air and water quality in the neighborhood, the quality of your housing stock, these are the things that drive health outcomes. And if you live in a community, where you have access to the things that you need to maintain good health, then your health outcomes will be significantly better. But if you're living in a community where you don't have access to fresh fruits and vegetables, because there's no grocery stores that are within a close distance proximity to your community, it makes it difficult for you to purchase the things that you want to put out in your refrigerators and on your dinner table that are healthy. And if you're living in a situation where your economic status is such that you have limited income and limited resources, then the food choices that you make for you and your family are going to be influenced by your income, not necessarily about what's always healthy, because healthier food is more expensive in a lot of cases. And then we'll say, "Well, why don't you just change your economic status?" Well, if the job opportunities are not available for you and your community, or if the jobs are - there's a lot of jobs in Grand Island and places like that. But if there's not transportation, and you don't have means for that transportation, then that creates a problem for you. And so, these are the things that drive what we call the social determinants of health. And so our work, our mission with the African American Health Equity Task Force, we started off calling ourselves the African American Health Disparities Task Force, but we wanted to shift our thinking to a more aspirational - we want to talk about, where do we want to be, right? And where we want to be is health equity. And so we're unapologetically concerned with the health conditions of black people. This is not a minority thing, and not to take hits or slides, but there are a unique set of circumstances that are attached to the enslavement of African people, really in this hemisphere, starting in 1519. When you look at the Slave Trade by the Spaniards, and the Dutch, and the French in South and Central America, and then escalating into around 1619, migrating up north to what they called North America. But it was a land that was inhabited by the Indigenous people. And then, so this whole notion of the enslavement of African people in this region has, from beginning begun the process of the social determinants of health, right? Because the lived environment, economic opportunities, housing, right? And from that moment, African people living in America were at a disadvantage. And that continued throughout generations. So you have enslavement from 1619-1865. But even longer than that, Schuyler, because with the enactment of Black Codes and African American men forced to work in steel mills and coal mines in Alabama, Tennessee and other parts of the south, after being arrested for vagrancy, and then the inability to accumulate wealth through the sharecropping system, and just the debt that begun to just weigh upon freed African people living in America. From generation to generation passed on, and then even as we began to migrate into the north, and beginning to fill some of these jobs in during the industrialization. But then, as these jobs became unionized, and then the migration of those from Western Europe began to come in from Italy and Ireland, and other places like that, and Poland, they took those jobs. They displaced folks who had migrated from the south and moved up to the north. And so then, this whole economic disenfranchisement of African people living in America, has created such a wealth gap, that even today, in the year 2020, for every dollar of wealth, a black person has in America, a white person has $18. And so the medium, I believe, and you guys are students, so go look up this data, but it's about African Americans who have about $18,000 of wealth, versus over $100,000 by whites, and I'm not talking about income - I'm talking about wealth, and why is that? Well, post Second World War, and the beginning of when soldiers began to be able to purchase homes, as a result of the GI Bill. They were pushed into communities, segregated communities, and then red lines were drawn. And soldiers couldn't even use their GI Bill that they had earned on the battlefield, fighting for freedom for other people, and forced to live in communities that just create an economic disparity. And then as banks, over time, as banks value property, because what is your biggest asset, is your property, right? And then one of the factors that they put into, in terms of valuation of your property, is the demographics, let me say, of that community. So black folks living in black communities, buying homes, investing in homes, but then getting less equity out of their properties than white people in white communities, right? Then you have what I call ghetto taxes - if you have your car insurance, it's going to be higher if you live in a black community than if you live in a white community. Life insurance - higher premiums, if you're black, than if you're white. So all these things, they just suck the wealth out of black communities. And then finally, the interaction with the criminal justice system. Whereas, black people are disproportionately arrested and convicted for crimes, higher bales, longer sentencing. And so what happens when a young black person gets in trouble with the law? Well, it's grandma and them, that have to dip into the savings, the dollars that they began to generate wealth with, or that they would want to pass down to their family members, right? Second mortgages taken on that house that they finally paid off, to pay legal fees and things like that. And so this whole cycle, is just again, sucking the wealth out of the community, which creates and feeds into these disparities. So this is the level of how we want to attach these issues of health inequities, or health disparities, as opposed to just doing what the traditional health fairs and giving people balloons and coffee mugs, and thinking that that's going to change outcomes.

Schuyler Lawson  15:39 
And in light of this, to the other daunting challenges that you listed, what is the African American Health Equity Task Force's factor in alleviating or even solving the problems caused by this multi generational structural damage that's been wrought upon?

Reverend George Nicholas  15:57 
It's truth telling, right? You can't address problems that you don't recognize are problems. So we want to change the narrative about why these conditions exist. Right? And to focus more on systemic changes, and looking at systemic causes, so that our solutions will impact the systemic causes. Let me put it this way. One of the things that - I'm not critical of it, I'm just trying to make an analysis - is that one of the things that happens every year is, the beginning of the school year, I use this analogy all the time, is there's always this big push to get kids backpacks, and we would give kids brand new backpacks. But yet, there's no data that says the reason why black children are underperforming in an urban schools is because they don't have a backpack. And so the the remedy has nothing to do with the problem, because if the child is still going to a failing school, in an at-risk neighborhood, and if mother and father still don't have the kind of economic opportunities, if the air and water quality in their community, all these other factors, if that has not been impacted, then the fact that this child has a new backpack really will have a limited, if any, impact upon their ability to achieve academic excellence. Not talking about passing, right? See, we've shifted, I think, and I'm so proud, brother, that you're working on your PhD, right? But the thought process that we're just - think about this man. That we're putting a lot of energy, and it's necessary because of what the current reality is, to get kids, our children just to pass. And what we really should be pushing is scholarship and academic excellence. What do you have to get - a 70 or 65 to pass, let's say, 70? If you get a 70, that means that 30% of the information that was provided for you, you didn't get. 30%! That's right! So our work is to look at systemic issues, raise concerns, and then bring forth community collaborations to bring community based solutions, and then engaging partners, institutional partners, to invest their resources, and to the solutions, whether it be financial resources, whether it be intellectual capacity, whether it be access to information - whatever these institutions have, that could be available to them. We were saying, use those resources and let investors in to create a problem solving as it relates to the issues in the African American community.

Schuyler Lawson  19:33 
Thank you for your response. It definitely helps our listeners understand the breadth of what the African American Health Equity Task Force does. I do have a particular question. What have been some of the approaches that the Task Force has taken with regard to the COVID-19 pandemic?

Reverend George Nicholas  19:51 
Well, there we have a good news story, Schuyler. And it shows - it's actually proved positive to our hypothesis of the importance of community collaboratives and supporting Black leadership. Let me frame this for you. So we put out a report in 2015, about the conditions of the African American health conditions, which showed that -and people can have access to these reports on BuffaloHealthEquity.org, BuffaloHealthEquity.org. And in our initial report, just using state and county data, and concentrating on five or six zip codes where the predominant number of African Americans live - on the East Side of Buffalo - we found that in terms of, just looking at chronic disease, that an African American who lives in one of those communities has a 300% more likelihood to have a chronic disease than a white person who lives outside the community. It translates to about 10 to 12, lost years of life. So we were equipped with the data, and so when COVID-19 emerged, we knew that because of the high rates of diabetes, asthma, and heart disease, which are three comorbidities, that make an individual more susceptible to COVID-19, that the African American community would be hit the hardest. Also, when you put on top of that, we know that a lot of the essential workers who work in these health care spaces, health care aides, security people, people who work in dietary and environmental services, as well as the nursing and doctors in the medical area, but there's a high concentration of people from our communities that are employed at those other level of jobs. And so they would be coming into these environments where COVID was present, and then going back into their communities, sometimes using public transportation, sometimes catching a ride with their uncle and them, right. So we know that there was a real potential. So we reached out, back in March, to the county executive, and the health commissioner and some other leaders in the health care field, with leaders from our community, Dr. Vasquez, and others. And we said to them said, listen, what's your plan? We know this is coming, we laid out the possible vulnerabilities of our community. And at that moment, they really hadn't began to think about those things in those terms. So what we said to them was, listen, we're gonna come back to you with a plan, a plan of how we're gonna address this issue. And we need you to resource it. We need you to support it. Right? Because these are our dollars as well. And so after some going back and forth, and what have you, we were able to use some of the Medicaid reimbursement monies through the district, through Millennium Collaborative Care, through Erie County, being able to stand up what we call the COVID-19 Response Team. And what we did, Schuyler, we've got 15 churches on the East and West Side, and we developed these COVID response call centers. We got a list for the board of elections and other resources, and we had our targeted area and we hired a lot of younger people - a lot of them were home from college, what have you, got them an iPhone, got them a laptop, got them a list. Dr. Vasquez and his team through GBUAHN had developed this tremendous IT system that allowed for our responders to actually make appointments for people right there, from their call center or what have you. So we literally called almost everybody in our community. What we learned too, there's still a percentage of people in our community that don't have a cell phone or landline. So we engaged the National Witness Project, who are already doing some community engagement, community health work type stuff. And we said to them, "Knock on these doors for us because we can't reach these people." And so why were we reaching out to them? Well, we want to find out one, if they had any symptoms?  Two, have they had any access to tests? Three, do they have a primary care physician? Four, do they have some food insecurities? Five, how are they doing mentally? So we ask these five questions pretty much and these people were trained. And we were able to not only ask those questions, but to give some kind of response to attaching people to help. So if you're having some of these symptoms or what have you, Hey, get to your get to your primary care. Oh, you don't have a primary care? Well, we'll do our network. We got GBUAHN, we got Jericho Road - we can plug you into a primary care physician. Oh, you need transportation? We'll come pick you up. You need food? We engage with Alex over at the African Heritage Food Co-op, who does a tremendous job. So we said to Alex, here's a chunk of money, get what you need, and then let's set up a delivery system. And so, when people needed food, we were able to get that to them. We worked with BestSelf, if there are people needed some mental health stuff, because people are dealing with a lot of stuff - make that appointment for you. And then when we learned that there weren't enough testing sites within the community, we were able to stand up the testing site at the Leroy Coles Library. We said to those who had access to testing, we need tests in our community health centers. Because the people at the Community Health Center, the people at Jericho Road, the people at GBUAHN, Dr. Ilozue at Rapha Medicine - those sites, they're already dealing with people in our community, prior to COVID, so they need to have access to the resources in order to get them some help. It wasn't easy, but we kind of put this plan together. So here's the good news. So when we started the project in March/April, and the first data started coming in. Now nationally, African Americans are dying in about two and a half to three times their population rate as it relates to COVID. Erie County - African Americans make up 14.6% of the population in Erie County. The early data was showing that about 33% of the fatalities were from the African American community, which was trending pretty much at the national level. But then, as we did our work, made our calls, connected people to resources, gave people access to PPE and others. And not only us, but there were other partners in the community. So what happened is, we were able to stimulate and generate some energy that not only our project was having an impact, but it loosened other resources and other things within community where others were doing some really great work as well. So as the data began to come back, we saw it trending downward to the point where in June, only 16.7% of the fatalities in Erie County were from the black community. And to make it even better, the latest data we got just this week, even in the midst of the second wave and the trending upward, that only 14.7% of the deaths are from the black community, which was right in alignment, statistically in alignment, with the population. We're one of the few cities in America that can make that claim. Why is that? Black leadership with a vision. We're already working in community around these issues. Connecting with resources and systems and institutions that have an obligation to serve the black community. If you're the County Health Department, well, the last I heard the black community was in Erie County right? So you make these systems do what they are designed to do, what their mission is. And then other health care providers and institutions, insurers and others, Kaleida, and others and say listen, we need you to invest your resources and help us get this thing done. But, also critically following the leadership of health care professionals that were already operating within those communities. Guys like Dr. Vazquez, guys like Dr. Glick, right? Women like Dr. Ilozue, and Dr. Ansari, who are already there on the frontlines, so they have to be resourced and be equipped, so that they can do what they need to do. And the results are undeniable. Data speaks for itself.

Schuyler Lawson  30:19 
Yeah, I mean, compared to nationwide data, it's an anomaly. The work that you described is just amazing - the coordination and just the scale of it, to achieve that type of outcome compared to national statistics, where blacks make up a significant portion of the - a significant and disproportionate compared to their population, a portion of the COVID-19 deaths. That's commendable.

Reverend George Nicholas  30:47 
And shout-out to Reverend Kinzer Pointer, who's provided great leadership on this, and others within our team, Dr. Willie Underwood, Rita Robertson, Kelly Walford, we have just a wonderful team of people who have worked tirelessly on the issues of health equity. But what we can't do is, because really, what our vision with our Buffalo Center for Health Equity, the African American Health Equity Task Force, and then the University having its community research institute under CTSI, under Dr. Murphy who,  and this is another really great outcome, is that standing up that Institute and the system embedded in the University that is focused and its mission is to look at health disparities, and to research, and then not only research, but to come up with remedies and engaging not only the medical school, but the other academic disciplines - the School of Education, the School of Law, the School of Management, the School of Nursing, the School of Social Work - they're all partners with us in this work, so that when we start coming up with solutions, then we're able to draw upon the expertise that operate within these schools to come up with innovative and creative responses to some of these issues that are creating these health inequities. Dr. Tim Murphy has been fantastic, who's head of the CTSI, Dr. Margaret Grimsley, Dr. Henry Taylor, Dr. Heather Orom - they've all just been great partners with us in this work to the point right now, where we were able to get, through the School of Nursing, a grant from, what they call a Cory grant, where we're going to be actually looking at how the impact of mental health has on these communities post-COVID. And from what I understand, it's one of the first kind of community/university kind of collaborations to look at issues that are specifically designed to provide information but also support for issues in our community. So we're making some progress and we're really excited about it.

Schuyler Lawson  33:31 
I'm excited about it too. It's great to hear that all this progress was made at the community level, at different types of institutional levels, dealing with the Erie County Department of Public Health, and also too, getting UB on board which is located within the community, so might as well have a stake and be involved.

Reverend George Nicholas  33:51 
Universities have a responsibility to do problem solving. What's the point of doing all this research and having all this knowledge if you don't take the research and knowledge to better humanity? So that message has been heard and university and institutions have been very responsive. And we're very hopeful in the future and about the future about the work we were going to do together.

Schuyler Lawson  34:24 
That's great. So I have another question. What is the Concerned Clergy Coalition of Western New York, and how do they relate to the issues of equity that you mentioned?

Reverend George Nicholas  34:39 
So, Reverend Pointer and myself and a few others were kind of the ones right after the death of Eric Garner, and we organize clergy, about 90 clergy, in the area to begin to start having conversations about those issues and what's happening here in Buffalo. And we began to start talking about, thinking about how we can provide leadership around health, economic development, criminal justice, and education. And so I kind of grabbed the health piece, and we've been working ever since on those on those issues. The Concerned Clergy represent - there about five or six different ministerial groups in the black community. And so they all kind of came together under this banner of Concerned Clergy. And we're working on these kinds of social justice type issues, doing our best to present a united front, even though we differ in some ways on issues theologically and doctrinally, but there's agreement, that we must come together to work for the betterment of the conditions of our people. And so we've been functioning pretty well, It's difficult, because historically, again, there hasn't been this kind of unity amongst black clergy. But we're not as divided as people think, but we're not as unified as we should be. So we're a work in progress, but the Concerned Clergy has been functioning, and certainly Reverend Pointer has been a leader in that group. But we've been really spending a lot of our energies around health issues. Bishop Badger has been swinging a lot of energy around education, so we're trying to span out our influence in these spaces.

Schuyler Lawson  37:21 
Thanks for providing that background. Another question: So as the Concerned Clergy Coalition of Western New York played any roles in addressing the issues surrounding the pandemic?

Reverend George Nicholas  37:39 
Well, yeah, so I wear a lot of hats. So when I'm operating in these spaces, the Concerned Clergy, I'm representing them, you know what I mean? We report back, and we have conversations about things. I know I can always depend upon these guys and ladies for support. And so the efforts around the pandemic have really been channeled through our work, through the Buffalo Center for Health Equity and the African American Health Equity Task Force. So the Concerned Clergy are part of that work. And then when other churches and other groups try to do things, we will support them and resource them, and it sort of works that way. One of the things though, what we did this week, was begin to start educating the community around the pending vaccine. And we had a conversation on, I believe it was Wednesday, with Dr. Alan Lesse, who is an epidemiologist at the University and really an expert on these issues of infectious disease, and so this issue with the vaccine because of our history. We know that the data has shown only about 43-44% of black people who have been polled so far, have said that they would be willing to take the vaccine, and I understand those low numbers. There's a historical context, there's a rationale behind...Dr. Michael Eric Dyson would say that black people are not skeptical of science. We're skeptical of scientists. And so we have to get over, I shouldn't say this, we have to enhance our understanding and knowledge around issues as it relates to research, we have to have more black folks involved in research, we have to engage in participatory research. And we have to engage more with institutions that have access to data and have conversations, so that we'll operate with a greater knowledge base around this vaccine. So that's what we're trying to do. The fact is that the FDA and the CDC have put the Pfizer, Moderna, and all the companies that are developing the vaccine through a rigorous four step process, that would certainly maximize the probability that when the vaccine comes into the public, that it will be safe. And in fact, I believe one of the lead scientists, in the development of the vaccine was an African American woman. And forgive me, I don't have - can't recall her name, right now. And so when the vaccine emerges, the decision that we make on whether or not we're going to take it have to be based on facts and knowledge, right? And we need to hear from - I know that Morehouse is going to play a role in investigation and disseminating and information into community about the vaccine. So we need to hear from black doctors about this, you know, and locally, hearing from me from Dr. Vasquez, and Dr. Underwood and people like that in community, who I trust. And if they say, Hey, this will be something that will be beneficial to our people and to our community, I will follow that leadership. But we have to be very - this is a very delicate situation, and we cannot be dismissive of people. When they express their reservation and concern about that, about the vaccine, and we should listen to their concerns and answer any and all questions with the hope that if the vaccine is going to be beneficial for our people, that everyone in our community does take it. And that, but we also have to be involved in the process of distribution. And so what good would the vaccine be if it's gone through all four phases of approval, but yet, it's not available to people within our communities. So we have to continue to advocate and be at the table and say, "Okay, we're high risk." We are already struggling with a lot of issues, we got a lot of our people who are working as frontline workers in these health care facilities. So we want to make sure that people within our community have the information about the vaccine, and also access to the vaccine, when distribution begins.

Schuyler Lawson  44:00 
Those are very important issues, and I imagine that the Task Force and the Clergy Coalition are going to play a big role in trying to have a plan for Buffalo's black communities as far as equitable distribution, and also to, like you said, an information campaign to build trust and address the roots of, the historic roots of the mistrust towards doctors.

Reverend George Nicholas  44:25 
One of the things that, one of the outcomes of our project is we've developed just piles of data now. I mean, we've made, I think, over 100,000 contacts with people, and so each one of them has a data point. And so we're going to be able to, as one of the outcomes of our project, be able to really make some really strong programmatic and policy recommendations about how do we can better serve the African American community based on the data that we're collecting. So we strongly believe that research will give you data, data will inform policy, and then policy will bring resources. And so we have to make sure that we are very aggressive in all four of those phases. Because really what's happened, Schuyler, over the years, is our people have been measured and surveyed and queried, and then institutions have have gotten tremendous grant and funding opportunities to do that. But then once we compile the data, and identify these issues, there never seems to be a follow-up of policy recommendations to address those. So it's one thing to survey people, find out y'all got a lot of diabetes, but then, Okay, this next step is not here, the programmatic things we're going to put in place to address those conditions, that has not happened at the level that we need it to happen. So that's one of the reasons why it's very important that we have this collaboration with the University and others around research - research is critical. One of my goals is to have 'research' no longer be a bad word in our community. Because we, you know, and I understand. So I've not done that yet. But now, we understand that the importance of research, and importance of research being done right, and making sure we don't take the data from the research to weaponize our people, but take the data to be a bridge to getting resources to change the condition of our people. And that can only happen when Black leadership's involved. And we got to be real about that. We need to insist that black leadership is involved, and we have to make sure that black leadership is black leadership, meaning, not just black people in leadership is not black leadership. There's a difference you see there, right? And so we have to have black folks who are in positions of influence and leadership to be unapologetic advocates for the conditions of their people, and not get tied up in the semantics of whether you should say to fund the police or not, that's the absolutely wrong conversation to have. And it's unhelpful, it's unhelpful critique for people in leadership to critique that phrase, without looking at it, but without putting your energy around the issues of why people are saying that. And so we have to understand the nuances of how can you be an advocate for black people? The only way you can do that is to listen to black people, and to share their concerns in an unfiltered unabridged way, so that we can really begin to start getting at the root.  There's a generation - your generation - I have four sons and one daughter, and your generation is very clear of the directness, and so I'm grateful to see that kind of the shift. Things like the unwillingness to play semantical games and to appease white institutions, but to say, listen, we have a right to be in this space, and we have a right to advocate for our people, and we have a right to use the knowledge bases and the things that we've learned from these institutions to better the conditions of our own people. And that is a critical, critical piece that I think we have to see in terms of shifting in our approach in our community.

Schuyler Lawson  49:25 
Very well put. And that actually leads to - I have a final question. Is there anything else that you'd like to share with our listeners? Any kind of, you know - you said a lot, and I'm putting you on the spot, but anything else before we conclude our interview with you?

Reverend George Nicholas  49:42 
I guess, I'm sure a lot of students listen to this. The issue around race; I think this is our season to really engage in real meaningful conversations about - and I like to to say, put it this way, to take the power of racism, or to diminish the power of racism in our culture. Well, as a theologian, I would be hopeful that we could eliminate racism, but also as a sociologist, (because I have a degree in sociology) understanding that I think our best hope is to be able to diminish the power of racism, and the power of white supremacy and the ideology of white supremacy and its influence on institutions to diminish that power that it has, I think is something that we could do, which is a realistic goal. And I think it happens through people engaging in transparent and honest conversations about the history and the present practice of white supremacy and systemic racism, and to engage in conversations that would define allyship, in the terms that centers the needs of black people in that allyship work, and to be cautious in our conversations about intersectionality to the point where we, I believe that we do that, but not at the expense of the needs of black people. And I think what has happened historically, post civil rights, I think that, at times, our desire to do intersectional work, and to do coalition work, has at times put the needs of black people secondary. So we have to be smart, cautious, learn from our past practices, and then to be innovative. I mean, to recognize that there has to be new approaches to things. I think folks in my generation have to make spaces for sunsetting some activities in organizations that may have been effective for a season. But there's a new opportunity here, and I think we need to make room and spaces for the next level of leadership. But I also will caution, the next level of leadership to not discount the wisdom of the elders. And so one of the things that diminishes our strength is when we have conversations of pushing the old folks/old guard out of the way, and you know, "this is our time," right? And I think by doing such, you diminish the opportunity to glean wisdom from folks that have been on the battlefield, and can maybe give some wise counsel on how to deal because the enemy is wise. And the enemy does not separate generationally, the enemy passes down the wisdom of how to maintain power and control down to the next generation. And that's why there's been so much success to keep this generational dominance. And so those are the things - the final things I'd like to share with folks and then just inviting people to log on to our website, BuffaloHealthEquity.org. And then when you see activities and things going on around campus, around community, around health equity, around justice, get engaged. Don't wait for somebody else to do this. This is your season, your responsibility. And if you're a person of good conscience, and there's so much happening right now, it's a great opportunity for you to get engaged, and to begin to shape the society and the way in which we want to be. And it's only going to happen if we get engaged.

Schuyler Lawson  54:35 
Thank you for those thoughtful parting remarks. And thanks again for taking the time to be interviewed on our podcast. We hope to have you on again to discuss future projects. For example, once the vaccine becomes available, how things are going to go with the Task Force and the Coalition with helping out with distribution and the information campaigns. We definitely want to follow up on that. I had a question. Is there a way that our listeners can learn more about the Task Force?

Reverend George Nicholas  55:09 
BuffaloHealthEquity.org. We have all the information and if you want to send us any questions, or anything like that, we have a way to respond.

Schuyler Lawson  55:23 
And for our listeners, are there any volunteer opportunities?

Reverend George Nicholas  55:27 
Yeah, I think so. I'm not sure right now, again, BuffaloHealthEquity.org. I know that we have some students doing some academic stuff. I think one thing too is checking with people like Dr. Heather Orom, Dr. Grimsley, Dr. Taylor, and Dr. Murphy, and Dr. Lesse. If any of them are your professors, and Heather Abraham, over at the Law School, reach out to them and say, is there something that I can do, in terms of support your connection to the Task Force? And we're always open, we're looking for ideas. We want to be a place to support and convene new ideas. So, I mean, there may be some things that - I had a conversation with a young lady that wants to do some internship work. And I said to her, that's great. So she said, "Well, what are we gonna do?" I said, "Now I want you to tell me what you want to do." You know, I'm interested in your creative minds. We don't need anybody just come run copies for us. I want to mine the intellect of young people, and mine their ideas. Do you know what I mean? As opposed to just giving them some task, right? Because I think that's where the power is. And so I would just encourage people, we would welcome ideas and thoughts, and let's see what we come up with.

Schuyler Lawson  57:16 
And again, listeners, that is BuffaloHealthEquity.org.

Reverend George Nicholas  57:18 
BuffaloHealthEquity.org. And also, we got another website of a project we're working on, called Pride in Place Buffalo. Pride in Place Buffalo. And it's a collaboration with LISC and AARP, where we're actually going to be doing some creative things, just about celebrating and loving our folks in our communities. It's gonna be real artsy, and just trying to - we've been dealing with this trauma, right, and we got to learn how to celebrate ourselves, celebrate what's happening in our community that's good. Celebrate the artists - we're working with folks from the Wakanda Alliance, and there's some folks that are just doing some great things on the ground, and we need to support them, and we need to resource them. If you go to BuffaloHealthEquity.org, I think there's a link, but there's other ones called Pride in Place Buffalo. Pride in Place Buffalo. And you'll see some exciting things, and there'll be some things we're looking for: artists, we're looking for all kinds of folks in that, so that would be a place to kind of link into something.

Schuyler Lawson  57:18 
Okay. Thank you very much. And, again, I'm Schuyler Lawson, and thank you all for listening to another episode of Buffalo HealthCast. Take care and be well.

Outro  58:44 
This has been another episode of Buffalo HealthCast. Tune in next time to hear more about health equity in Buffalo, the US and around the globe.