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Episode 14 – Race, Place, and Health: Clinician and Community Perspectives

Learning Objectives
1. Understand the historical and present-day role of land dispossession and property rights in determining health along lines of race and place
2. Learn how advancing individual agency and distributive justice can empower community organizers and initiatives
3. Understand the factors that promote and inhibit long-term resiliency and sustainability of place-based initiatives
4. Learn how we can reimagine health by decolonizing wealth and philanthropy in modern society
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The Clinical Problem Solvers Antiracism in Medicine Podcast Series aims to equip listeners with the consciousness and tools to practice antiracism in their health professions careers. Learn more.

Audio Transcript

Naomi Fields: Hey, y'all. This is Naomi Fields, and welcome back to another episode of the Antiracism in Medicine series of the Clinical Problem Solvers Podcast. As always, our goal in this podcast is to equip our listeners at all levels of training with the consciousness and tools to practice antiracism in their health professions careers. This episode is entitled Race, Place in Health, Clinician and Community Perspectives. Today we're focusing on how racism manifests in the built environment and how community, as well as individual level efforts, can redress these inequities. This is the second of three episodes interrogating relationships between race, place, housing, and health, and we're so excited to get a window into how our guests do the community-building work that they do and how these efforts can help us better understand solutions to the problems we see clinically. I am absolutely thrilled to be hosting this episode with the incredible Lash Nolen. Hey, Lash, can you introduce our guests?

LaShyra Nolen: Hey, Naomi, it's great to be here with you. I'm so excited about this episode and our phenomenal guests. First up, we have Noelle Warford, who is the executive director of Urban Tree Connection, a grassroots organization in West Philadelphia that uses land-based strategies and urban agriculture as tools for fostering community leadership and power. Noelle was raised in Youngstown, Ohio, in a predominantly Black working class community. As the first member of her family to attend a four-year university, she received her BA in Women's and Black Studies from Denison University. Through her studies and travels abroad, Noelle developed an analysis of structural inequities that drives her professional work and life. In 2007, Noelle moved to Philadelphia to obtain her master's in social work from the University of Pennsylvania. Over the last decade, Noelle has worked in the nonprofit sector with the focus on program development, data and evaluation, fundraising, teaching and curriculum development, strategic planning, and organizational development and governance. Noelle has been a part of various city and statewide coalitions to advance racial and economic justice in agriculture and food systems. She's a board member of the Northeast Sustainable Agriculture Working Group and a member of the Philanthropy Network of Greater Philadelphia's Diversity, Equity, and Inclusion Committee. It's such a pleasure to have you, Noelle. Thank you for joining us today. Next up is Dr Eugenia South. She is an assistant professor and the vice chair for Inclusion, Diversity, and Equity in the Department of Emergency Medicine at the Perelman School of Medicine at the University of Pennsylvania, who is passionate about understanding and dismantling structural racism and promoting environmental and economic justice in Black and other minoritized communities.

As an emergency medicine physician, she provides care for diverse population with complex medical problems and witnesses firsthand how neighborhood environments impact health. As a researcher, Dr South is the faculty director of the Penn Urban Health Lab, a research action group dedicated to partnering with communities to build healthy and safe neighborhoods. She is interested in understanding the ways in which the physical and social attributes of where people live, work and play influence cardiovascular and mental health, chronic stress, and violent crime. She develops and tests neighborhood and individual level interventions. Dr South has studied a variety of place-based interventions, including vacant lot greening, abandoned house remediation, tree planting, and structural repairs to homes. Her research is funded by the National Institutes of Health, the Robert Wood Johnson Foundation, and the Centers for Disease Control and Prevention. Her work has been published in JAMA, PNAS, AJPH, as well as been covered by national and international media outlets such as The New York Times, The Washington Post, NPR, and Time Magazine. Dr South earned a BA from Harvard University and an MD from the Washington University School of Medicine and a Master of Science and Health Policy from the University of Pennsylvania. Dr South, thank you so much for joining us today.

Eugenia South, MD, MSPH: Lash and Naomi, thank you so much for having me. I just want to say before we jump in, it's such an honor to be here with you both and the whole team. I remember listening to your first episode about police violence and health with Doctors Rhea Boyd and Rachel Hardeman, and I literally remember where I was in my neighborhood. I was out walking when I realized this podcast is gold. Every episode that you guys have done has been thought provoking, boundary pushing, and just overall excellent. So I'm honored to be a small part of that excellence that's happening here today.

Fields: Wow, it means so much to hear you say that. It means so much. We're going to jump right in with our questions to get these juices flowing. So we have talked before on this podcast about how structural racism or the ways in which society systems and builds environments unfairly advantage White groups at the expense of Black and Indigenous folks and other persons of color. Dr South, you've written that, "Each time we traverse our neighborhoods, the environment is getting under our skin to influence our physical functioning, our thoughts, our behaviors, and our interactions. This often happens without our conscious awareness." I was wondering if you could each talk about how you witnessed this embodiment of the built environment and communities that you live and work here in Philly and elsewhere.

South: Yeah, absolutely. So I can go first. So I think at a high level, we need to understand the ways in which structural racism, both historical and ongoing, shape the built environment, both the built and natural environments. And have you ever thought about the fact that if someone blindfolded you, dropped you into a neighborhood and you sort of took a quick look around, that you could probably roughly guess the income level of that neighborhood? If you were in a neighborhood with single-family homes with well-manicured lawns and tidy treelined streets, you would know that you were probably in either a middle or upper income level neighborhood. If you were dropped into a neighborhood with homes that had crumbling facades, abandoned buildings with blown out windows, vacant lots filled with trash, no trees, you'd know that you would probably be in a lower income neighborhood. So why does the physical environment of a neighborhood, our physical surroundings, when we step outside of our house, track with income and also, in many ways, track with race? So in some of your prior episodes where you've covered things like redlining, Federal Housing Administration, we know that certain neighborhoods got intentional investment from the government, and many neighborhoods were disinvested from. And that level of money, that level of resources predicts and is what allows people and communities to invest in those physical spaces and structures in their neighborhoods. And is that connection that I don't think a lot of people make very clearly. There was in one of Biden's Build Back Better bill, there's a provision for planting trees. And when that came out, there were actually a lot of people who sort of dismissed and mocked like, "Why are we going to spend so much money on trees?" But if you are wealthy and you live in a wealthy neighborhood, of course you have trees and you kind of think like, "Oh, well, that's just a nice to have thing." But it's not just nice to have. There are very clear health benefits.

And so when we think about segregation, it's not just the division of people by race, but the division of resources and health risks. And one of the things that is divided with segregation is the physical environment. And so this is something I didn't think about until I was a research fellow. It's really not something that's part of our medical education, at least when I was in medical school. I think that's starting to change a little bit. When I moved to Philadelphia in 2010, that's when I was introduced to this concept of the built environment having such a strong impact on health. I learned a statistic when I moved to Philly that there were 40,000 vacant lots and abandoned buildings in the city of Philadelphia. And I'm like, "That must have been a typo." I'm like, "It's probably 1,000. There's no way there can be that much vacant and abandoned space." But that was the true number. And so one of the first studies that I did was a qualitative study actually asking people in West and South West Philadelphia, where Penn is located, "What do you think the impact of these vacant spaces is on your health?" I want to read a quote from that study that has stuck with me over a decade that really crystallizes that connection between place and people. And so this person said, "It makes me feel not important. I think that your surroundings, like your environment, vacant land, affects your mood, affects your train of thought, your thought processes, your emotions. And seeing vacant lots and abandoned buildings, to me, that's a sign of neglect. So I feel neglected." And so you can imagine, back to your question about how does this manifest in my work, if you are an individual who steps out of your home every day as you're going to work or going to pick up food from the grocery store and you feel neglected as you're walking the neighborhood, how does that impact our health? It has an impact on our health, on our well being, our ability to connect with others in our neighborhood. And we'll get into that more later as I'm talking about my research.

But there are very clear connections that we've seen in the research world between place, what's happening in our bodies and how that then ultimately manifests in health and contributes to the racial health disparities that are so deeply entrenched that are so important. So these links are very clear between environment, health and well being.

Fields: Absolutely, absolutely. Noelle, what is your take on that question?

Noelle Warford, MSW: Yeah, I think Dr Gina just laid it out so clearly to especially talk about the conditions we find ourselves in. And I think from an agriculture perspective, I really think about thinking about this from a historical perspective, too. And quite often, we talk about the land as being sort of the original scene of the crime in the US, where settler colonialism began, where this land was stolen from Indigenous Peoples, and how when we talk about the built environment and health and literally populations being wiped out, the US is founded on that history. And then if you build on that, African Peoples being stolen from their land, brought to the US to sort of build up the economy as we know it, and land being the place where people have their rights. Property rights is critical in the US in terms of even today when we look at tax codes and benefits. And if you're not a landowner in our history, you weren't a person, that had no rights to vote, from women to Black people. And that still holds true in so many ways. So all of the things that Dr Gina spoke about is really rooted in this long history and legacy. And so we really have to think about when people are like, "Well, what does that have to do with where we are today?" Is that it is deeply entrenched and something that we have to think about not just small reforms that need to happen, but deep structural change that needs to happen. And so we see this play out a lot when people come to the land, particularly Black and Brown people, is that there's sort of like this connection to it.

But then also there's, at the same time, deep repel because there's this also psychological trauma that happens when you've been forced to come to a place where you don't get to develop the relationship with your environment and the land that is in a way that is able to actually serve you, but exploits you and is harmful to you and your community. And so a lot of our work is thinking about how do we put that-- how do we name it, unpack it, and then develop sort of new alternatives and relationships to land and the environment in different ways.

Nolen: Absolutely. Thank you both so much for that, because I think what we're really getting at is thinking about the different ways that racism can manifest in our built environment and how that can make you feel. And it really reminds me of this idea of internalized racism because you see the way that society is treating you and how they're kind of expressing to you what you deserve to have. And in some ways, you can start to feel that way like, "Oh, well, maybe I don't deserve to have trees in my environment, and maybe I did something wrong to not have a neighborhood like those folks across the street or down the way." And I think that the beautiful thing about the partnership that you two have is how you've been able to really put the power back into communities and allow them to kind of lead the efforts that they'd like to see to improve their communities. So in particular, I'm thinking about a project that you all worked on together, a three-based project to rebuild a garden in West Philadelphia. So I'm wondering when you were going through that process, why you felt it was so important to engage community members at the initial onset. And Noelle, in particular, I'm interested to know why you felt that aspect of that project was really important. First, engaging community members and how academic institutions can fail to do this at times and what that can lead to when it comes to community partnerships that are sustainable.

Warford: Yeah. And I would say that nonprofits are guilty of this as well. I come out of the nonprofit sector and it's everywhere. I think one important thing to understand about our organization is that we are not just a food access organization where we grow people for people to have access to food. It's really important and it's a need in the community. We work in a 96% African American community working class where access to food is limited. However, our purpose is that need on top of the compounding crisis that we're in only increases. So unless there's deep sort of change and people have a sense of agency about their ability to make change happen, then the needs will sort of outpace our ability to respond to them. I think that's probably one of the biggest lessons of COVID, this is like an ongoing crisis where the health care field can barely manage, nonprofits can barely manage. And so our work is really about how do we develop community leadership for people to see themselves as able to transform society, particularly Black and Brown people. How do we see ourselves as the people who will sort of bring about the society that we need? And so we do that through food and land sovereignty work. So building community leadership and people's sense of agencies is really critical to being able to transform society. That is the mission. That's sort of the north star of our organization. And so when we had the opportunity to work with Dr Gina, and she approached us about this project, we were really excited about it. And then there's also the hesitancies that come up with academic institutions which are like, "Okay, what is this for? What are you all about?"

Because quite often, these sort of institutions come into neighborhoods and sort of develop their research, and then at the bare minimum, they don't even share what that research is for and, in a lot of cases, most certainly not used to actually improve people's lives. And so the first time Dr Gina and I had a conversation, I was like, "Oh, we are on the same page 100%." And then as I started to learn more about her work and just the way that she's so rooted in community, it was really easy for us to kind of develop the methodology of, like, "Okay, how can--" We had decided to do some door to door canvassing and then develop a series of community meetings, because we had a sense from being in the neighborhood for a couple of decades of sort of where that space was and what people's concerns would be. But things are constantly changing. And so it was really important to talk to people. And then this garden in particular is situated in a particular place where there's a mix of homeowners that have been there for two, three decades. So family homes that have been around for a long time and seen a lot of things. And then there's like-- it's also right next to subsize housing where there's a high rate of renters. And so the perspectives are going to be different and the needs are going to be different based on how long someone has lived in the neighborhood and what they've seen, and also people's relationship to each other and how they use space together. And so it, one, affirmed some of the things that we knew. And then there were just some other things that came up that were really important, I think, in the process of talking to people. And also I think there's this false idea that if you build it, people will come, and that's just fundamentally not true. If it's not rooted in people's experience, then there's key things that you miss that you'll have an uninformed perspective. And it's often those little things that create an opportunity for big changes and shifts.

And I think one of the most important things that we learned is that we could have pursued this project with big design changes and create this big sort of thing, but that's not where people are. People aren't even coming to the space. And the more we talk to neighbors, they're like, "We don't leave this porch." And we're like, "Okay, safety. Safety is the first thing. We have to establish a sense of safety here." So simple things like lighting and walkway paths and clearing the space and things that will attract more kids to come. Those were key things and I think quite often, we can be guilty of having a vision or an idea that actually outpaces where people are. And if we actually want this to meet people where they are, then we have to do the process of including people in the process, having them be a part of key decision making, and then also build that trust over time.

Nolen: Yes, yes. It sounds like what you're getting at is you can have the most fire vision idea, funding, all of that, build it, but if you don't include the community from the outset, you might not even be meeting the needs that you initially were hoping to address because they weren't involved in that initial process to begin with. And I think this idea of, like, "We can do this together. We got to have each other's backs in order for us to progress." It's also a message that I'm hearing a lot in hearing you speak. And Dr South, I'm interested to hear how this has become such a critical part to how you think about research and doing work with community, because the ivory tower is real. And I think that you've been very intentional to really be with community and to kind of be very explicit in who you're for and what you're trying to do. So can you speak a little bit about why that's so important to you and how you've been able to make those sustainable partnerships in such a meaningful and intentional way?

South: Yeah, absolutely. I think the first thing is that it just goes back to people. And one of the things I love about my job is just that I get to talk to people and I get to know people like Noelle and to, like Noelle was saying, meet people where they're at and use the resources and the power that is within the ivory tower and within those academic institutions to be a catalyst for change in communities. And so that's really one of my sort of secret missions of my work, is to bring resources from over here and distribute them over here. Resources, power, money. And I'm slowly trying to chip away at that, because if we don't do things that way, we will create solutions that are not actually solutions or just fantasies we have in our mind about sort of pretending to address problems. I think a concrete-- just to zoom out from the big picture to a concrete thing, I had this picture in my mind of when we are trying to enhance the space so that people-- a green space that people will come and use it and reap the health benefits. We need to have seating. There needs to be place for people to sit and tables if people want to eat. And one of the things that we heard from the door to door canvassing that Noelle talked about and just talking to community members was they don't want seating there. They didn't want seating in this particular place because of the concerns about safety and that that would perhaps attract people that they didn't want to be in the space. And so that was such a key example of how you may have your ideas about something, but it's going to be different when you actually talk to the people who ultimately the space is for. And so we've come up with some other solutions around that, for example, having portable chairs and tables for when people do want to have an event in the space, rather than having something permanent.

But I think just back to your comment about the ivory tower, for people who want to do work like this from within academia, and there are many listeners probably who want to do this type of work from within academia, I think you need to really be very clear on your purpose and your mission so that you can withstand all of the barriers that are going to come up, because this way of doing things is not the norm in academia. Academia is not set up for this. The structure is what's valued, how you get promoted as a faculty member. It's not set up for this. And so you really need to be clear on your own purpose and be strong in that so you can sort of push past those barriers. And then on a very practical level, because of all the barriers that people within academia face who want to do this type of work, you have to have your community of people around you who support you, and that's like who truly support you, because there are a lot of undercover haters, as we all probably know, who may say one thing, but in the background, they're really not supporting you. And they're actually, in small ways, sort of tearing you down. And so you have to find your community and know who your people are, both like mentors and sponsors, peers and others who you surround yourself with. And then the final thing is, this is actually advice that I heard when I was a medical student at an SNMA talk. I wish I could remember who said this to attribute them, give them credit. But someone was saying, "When you go to work, you need to put your raincoat on so that all the stuff that comes at you, it just rolls off. So it doesn't get inside. It just rolls off so you can continue on in your mission of what you're trying to do."

Fields: That is going to be one of the hashtags from this episode. Put your raincoat on. I think that is just fabulous. And Dr South, when you were talking about clarity of purpose and mission and how part of that for you is really moving the power that's in the ivory tower to bring resources to the communities that these health care systems really should be serving in a different way than they are right now. I feel like, as I've followed your work over the past several years, that's just always been so clear that that was what is underlying what you're trying to do. And I think it's abundantly clear in the NIH funded RCT that you just got, which will invest almost 10 million dollars to invest in disenfranchised neighborhoods at the levels of communities as well as individual households. So congratulations on that. And I wanted to know if you could talk about the process of transitioning your previous smaller scale RCTs into this bigger push and broader scale intervention.

South: Yeah, absolutely. So we have done-- and I say we because team science has been a very big team effort from the beginning. And so we have done two randomized control trials, one of vacant lot greening and one of abandoned house remediation. And those were led by my mentor and sponsor, Charlie Branas, who is at Columbia, and is an amazing sort of thought leader in this space. And in addition to those, I've done work around trees. I've done work around structural repairs to low income owned homes. And so I've studied a bunch of these interventions in isolation. So we look at this intervention, this intervention, this intervention. But I really wanted to know, what if we combined all of these interventions? Because we know it's not just one thing. All of these aspects of the built and natural environment are impacting people at the same time. And so what if we have an intervention where we actually do all of it, all together at one time? And then the other thing that I've been thinking about a lot more recently is economic justice. And so I've done a lot of work in the environmental justice space. But money is also incredibly important for individuals, for households, for communities. And so what if we also added on a suite of economic focus interventions to households? So I teamed up with my MPI on this project, Atheendar Venkataramani, who is an amazing health economist also at Penn. We actually went to medical school together, which is really cool. We were in the same medical school class. We then didn't talk to each other probably for like 10, 15 years, ran into each other in the halls of Penn, in Blockley Hall, a few years ago. And then just in conversation over time, when this opportunity came out, I immediately thought of him. And we teamed up to get this grant in.

So we wrote this grant truly from a place of passion and just deep caring about coming up with innovative ways to address these just deeply entrenched issues. So we have this intervention that we created that's for place-based interventions, for economic focus interventions that includes connection to benefits, financial counseling, tax preparation, and availability of emergency grants of up to $400 for households, all of which all of these things individually have evidence but have never been studied collectively as a whole. And so we believe that this type of big push intervention will really have the opportunity to potentially address these deeply entrenched health disparities. The other big positioning is that this is the first time that I have funding from the NIH. This is the first time that I am the PI of one of these studies. So the other randomized control trials, my mentor was the PI, and I was intimately involved in them. I wrote papers from them, but I wasn't the PI myself. So this is a big transition for me on a sort of personal, professional level. And I'm really excited about it because having a grant from the NIH gives you credibility. It basically gives you street cred within the academy. And so I'm seeing that as like, now I'm going to be able to do even more and push even more boundaries because as my husband now says, I'm undeniable. And so when you reach that place, it's so exciting to see the doors opening for me that will allow me to open doors for others. And for me, that's really what it's about.

Nolen: I feel like we're getting all the hashtags today. I love that, the fact that you are undeniable and the way that you're doing it for the people. And I think the beauty of the work that both of you are doing is that it's sustainable work. You're actually creating a built environment that's led for people. And I think that an ethical tension that I often see within academia is that you can apply for a grant for a community, and after you apply for that grant, you get to say, "Hey, I won this grant." You get to write a paper about it, and you, as the person who's affiliated with this academic institution, gets to gain currency from that. But then what can happen is once that grant period is over, if the project isn't sustainable, that can destabilize communities because you've then created a resource that they've learned to rely on, and then you take it away. And I think that this can be a process that I see a lot, especially at academic institutions. Noelle, I know you talked a little bit about how nonprofits can also engage in this work. So I'm wondering, what are your thoughts about that and how have you seen it be done the right way, where we take these opportunities and make them long term investments into communities that lasts longer than just that one grant period.

South: So, yeah, I deal with this tension in my own work. And the reality is that our academic institutions are not set up to support sustainability in communities. So we have to sort of Jerry rig things to get to a place that feels true to where we can do the work and feel like we're not causing harm. But grants, for example, you're not allowed to build into an NIH grant sort of a plan for sustainability to fund because sustainability requires money. So you're not allowed to have a budget, though, for after the grant period is over to continue the work. So I think there is work that needs to happen around just the structure of how we do research, the structure of how academic institutions support researchers who want to do sustainable type of work. But some of the ways that I've thought about doing this… So one is trying to look for funding elsewhere, outside of the grant, that can be available for sustainability purposes. So, for example, with the vacant lot greening trial that we did, my mentor was able to find funding so that at the end of the study period, all of the vacant lots that were in the trial, many of whom hadn't been greened, were able to do greening work. In the project that Noelle and I are doing together, we've been talking about sustainability, like, "Who's going to take care of the land after we do these kind of transformation to the land?" And so we're building in some sustainability practices with our partner at PHS, the Pennsylvania Horticulture Society, who will continue to mow the lawn, pick up trash on a regular basis, to make sure they're doing that, and any new plantings that we might do, making sure community members have the tools they need, the trash bags they need, anything they need to keep that work going. And then I think the other piece is involving policymakers.

So a lot of work with land and vacant and abandoned spaces, you need policymakers on board to think about what is happening to that space. This is an area of ongoing sort of discussion with various policymakers, but you have issues of land justice. It's actually interesting that Memorial Garden space where we're working is made up of probably six or eight different parcels of land. And there's different people who own the different parcels of land, even though when you look at it, it looks like one big parcel. But the city owns some, some individuals own some. And that's true of vacant spaces across the city. The city doesn't really have a great way right now for community members who want to own the land, who want to take care of the land, for them to be able to do so. And that's a huge sustainability question and issue. So we're working with policymakers and also working with community members to help them try to advance this issue with policymakers on issues of land justice. But I would love to hear what Noelle thinks about this issue of sustainability as well.

Warford: Yeah, totally. And I see this very much mirrored in nonprofits, where it is really frustrating, I have to say, because the people who have the wealth, it is generated off of our communities. And so to have to go through the processes and the hoops that we have to do to take care of the basic needs of people from resources that have been stolen from our communities anyways is ridiculous. But it's part of the job and the work that we have to do, tapping back into those resources. So quite often, there's a lot of expectations or limitations to the funding that organizations can receive, and quite often, funders have more say on the ground work when they're not actually connected to communities. And quite often, nonprofits end up chasing money in order to keep their doors open that can lead to mission creep, that can lead to a lot of restrictions, that can require things that just create so many administrative tasks that really take you away from the role of what you should be, which is leading to transform your communities. And so it's part of the work that I do in philanthropy, too, is how do we-- and there's a lot of great work out there around how do we decolonize philanthropy. That's a whole other tangent we could go on. But I think that in terms of sustainability, one of the things that I always advocate for and I know a lot of nonprofits advocate for is that we need general operating, multi-year, long-term investments. If we're talking about actually changing, particularly like place-based initiatives, that there needs to be a deep and long investment and that the work is slow. And that philanthropy or anyone who is providing funding, if you want to be addressing root cause issues, like poverty and all the things that come connected to that, then it's going to take a deep investment and it's going to take time.

And then also, I think the part of the sustainability that-- part of what we built into this project, too, was how do we create stipends for community members to become land stewards. Because we know that quite often, even young people, like high school age young people, are in such difficult positions financially that they don't have the time to be participating in recreational things. So it's always competing with time that they need to be paid to survive. And so we've really done a lot of work of getting funding that will provide people with stipends so that they're not caught in that sort of thing. And so that's part of what we did with this project, it was building in some community stipends so that people can-- because people want to be doing it, they want to be attached to the work, but they also need some support around that. And I think at a little bit of a more macro scale connected to that, too, is that our role as an organization is really thinking about how do we build a community-led food system that -- and coming from a social worker's perspective, I remember the mantra that was put in my head is that your job is to work yourself out of a job. And if you're not doing that, then you believe that things can't change and that things will always be as they are. And so if we're actually trying to create systems change, what's the things that we're doing today that helps create different conditions for tomorrow? And part of that is that a lot of our work is how do we build mutuality with community members so that they are tapped into a sense of agency where they're like, "I want to be a part of the solutions in my community. I can see myself as being someone who leads a local food system in my neighborhood." Like, "I can see that for myself, my family. I want to be a part of the solution and a part of addressing what my community needs." And I think the sustainability, we need the resources, but we also need the people power.

Because a lot of the land justice, what Dr Gina was referring to, is that the council folks, they have all the say in determining what happens around land and they have to be accountable to the people that put them in office. But we can do the transactional work at the higher level and broker things, but really what we're thinking about is that how do we build people power so that community members are like, "This is what we want to see in our neighborhood. And if you don't deliver on that, you will not be in this position. We will find someone else."

Fields: I am loving the way that you both talked about how you have to have both these sort of long-term investments for sustainability and really getting stakeholders to understand that there is not a way to quickly fix these problems that have been sort of bubbling and boiling for years and years and years on end, that addressing the root cause in equities takes finances as well as time. And then Noelle, I really appreciate how you also illuminated that part of that funding also needs to go to supporting developing agency and community members to be leaders. And I am really appreciative of that thrust of what you all are doing at Urban Tree Connection in particular. And this reminds me of something that came up in the first episode of this series. It was entitled racism redlining and the path towards reconciliation. And our guests on that episode talked about how we have to work synergistically to both change public policy in ways that target inequities and invest in formerly disinvested sort of areas, and also that we need solutions that are incremental and create a more radical political environment within the communities that we live so that people feel and are more empowered to change things. And I think you both started to get into this a little more. But just to spell it out clearly, how do you sort of navigate the trade off or tensions between these slower structural changes and the more immediate, often individual upper interventions, to address inequity?

South: So I think one of the things I try to remind myself is that there are many different ways to be part of this fight that we're all into dismantle structural racism and the ill effects on health and well being. And there are also different seasons of an individual career. And so A, I think we need to value all of the different ways that people contribute to this fight. And some people are more focused on individual focused interventions. Some people are more focused on sort of higher level policy change. Some people are more radical in their approach. Some people are what we would, maybe from the outside, consider less radical or not radical at all. But all of the different ways that people work in this space are valuable and important and we actually need all of it. We need people who are going to say the craziest things like, "Burn the whole thing down and start over." And the people who are like, "Well, no, we can actually change this policy to do this and do this policy to do this." Because all of it is what's needed to move us forward. And as individuals, it can be frustrating when we're working very hard and we're not seeing the big changes that we want to see. And so I think it's important to remember that we don't individually need to do it all. We can't individually do it all. That's why we're in community with each other, why we're sort of building networks of people across the country who are doing this work. So I don't know if that truly answered your question, but that's sort of how I think about this work moving forward, to see real change and not getting disappointed or frustrated when I'm not seeing the big change that I want to see.

Warford: Yeah. I would just add that I think one thing that keeps us grounded in our work is that we understand this is a long and protracted struggle and that we're building on the struggles of people that have come before us, and then we're passing and raising up the next set of leaders who will take up the mantle of this struggle after us. And I think we hold the position that our current political economy, racialized capitalism, is not the economy that is going to meet the collective well-being of all people in the planet. But we know that that shift and that change, because we come out of just transition, which is moving from an extractive economy to a regenerative economy, is a long one. And so I think that we really think about what can we do in this period of history that we're in. One is raise people's consciousness. A lot of people are living in so much alienation, so disconnected from each other, that we really are trying to, through practice, through being on the ground, through being at the farm and the gardens and being together and meeting their needs together, that people's consciousness are raised that, "Actually, my fate is tied to your fate, and that we can actually engage in things that improve our conditions together in the community and that can be scaled up more broadly." I think the other thing is that we talk a lot about this is the period of organizing people, of building a base, building up people's leadership, bringing people together around a shared cause and concern. And I think that the other thing is that while we have this vision and we hold it as the thing that we're always walking towards, we know that people need their basic needs met. There's just fundamental improvements that people need in their daily life to survive.

And so we have to be a part of-- even though the reforms, they're never enough and that's never the big win, is really important that we win those because it increases people's capacity to engage. It gives people just a little bit more room to keep going, to engage more, to build more with other people. And so I think that that is sort of the incremental things that we need, while never abandoning the vision that the current society and the way things are structured are never going to be enough and that it is possible, there are alternatives, and they are winnable. And we know this because, as a group, and we do this even on the ground with community members, is we study political and revolutionary struggles from people before us because we need to know that that was real and that happened and that we're building on those for a more just society to happen.

Nolen: Noelle, thank you so much for those powerful words. I'm just sitting here just kind of reflecting on what you just said, and it's like basically, you got to celebrate the small wins, but always keep the greater goal and vision in mind. And I feel like, from what I've heard from both of you, the goal is liberation and agency for our communities. And I'm just so inspired from this conversation and just so thankful for the lessons that you have taught us today. And Noelle, I'm also thinking about how you were speaking on this idea of consciousness raising, and it makes me reflect on growing up, how my grandma was just trying to survive and my mom was just trying to survive. And now I feel like I'm the first person to be able to actually have the privilege to learn about systemic capitalism and racism and all these things, because I can actually sit back and read and understand those things. But when you're just trying to make it every day, you don't necessarily have that privilege. So I'm just so thankful that you brought up that point because it's so key and important. And I think now, just reflecting on this conversation, we've spoken about so much and I think some folks can listen to the podcast and be like, "Whoa, I don't even know where to start." So I'm wondering if each of you can maybe speak on for folks who are going into the clinical world, the nonprofit world, who have listened to your inspirational words today, what are some initial steps folks can start doing for getting into this work of that liberation and healing for our communities?

Warford: I can jump in first. I think the thing I would want to add is that-- and we say this a lot in our organization, is that theory doesn't live in academia and neither do ideas. They come from people. It comes from lived experiences. It comes on the ground. Because it's really important for us to always have a guiding theory, but knowing that it came from experience, and that that theory is only as useful as it is in practice. And so I would just really say that for any clinician, that you have to have a really strong sort of ideological position or kind of guiding principles and that you always have to root it in practice. It is so critical. And then you have to go back and revise that based on what you've learned sort of on the ground. And I think that one question that has guided both my professional journey, but also guides our organizational work, is that what are we doing today that helps make it easier for people to live, but also is the thing that is really moving us towards the changes that we need. So there's a revolutionary ancestor. Her name is Martha Honaker, and she says, "Politics is the art of making the impossible more possible." And so we always use that as a grounding for us in our organization, is how are we making the impossible more possible? And we are living in what was deemed by our ancestors the impossible. And so how are we in this moment doing that for the people that will come after? That is the thing I think that we have to really ask ourselves and grapple with, because right now, in this current climate, it can't just be about survival. So it's like, "Yes. And what are we doing to take that next step?"

South: And what I would say to build on what Noelle said, which is absolutely beautiful, is that we have this great honor as clinicians, for the clinicians who are listening, that we get to talk to people in a space where we have some automatic trust built up because we're a physician or another health care provider. And I don't think we take advantage of that enough to really learn about our patients lives, their homes, their families, their neighborhoods. And so what I would tell someone is the next time you're going to interview a patient and you've got to find out how long have they had the chest pain, when did it start, what does it feel like? Go a step further and ask some other questions about their life. And when somebody gives you an in-- because patients say a lot of stuff and we jump over and ignore half of what they tell us because we have this thing, this list that we need to get to. Sometimes someone might say something like, "Oh, I just have a lot going on. I think it started three days ago." "Oh, you mentioned you have a lot going on. Can you tell me about what's going on?" Asking those types of questions to really understand our patients, their lives and where they're from will help to keep us grounded in people. And so that's what I would ask people to do, is to be curious about our patients, not just the physical complaints or the emotional complaints they have, but about their lives and use the opportunity and the time that we have with them in the exam room to learn.

Fields: People say that you should never meet your heroes, but I just feel so grateful that we had the chance to have this conversation. I mean, these takeaways. Noelle, you saying-- basically what I got from that was you have to have your why. It needs to be very clear to you, especially so that you don't get caught up in whatever the culture, the political economy is that you are embedded in, whether you're in nonprofits or medicine or what have you. And I also think it was important that you said that to have the focus of making the impossible more possible. I think especially for those of us, speaking for myself, who are a little younger, seeing all these things happen can be very shell shocking. And there are times when I think we're not going to get anywhere. But having that vision, like you said, to go look back and say, "Okay, where are we compared to where we were and how can we progress and move forward from this point at which we're at?" I think it's really orienting and a universal principle. And then Gina, I really appreciate the reminder to take the time to understand our patients lives because that's where you get to understand the community that you're really in and that you're serving. That's the ultimate job as a physician, I think, is really to be embedded in that community and understand what people are going through and what they need from you. I am just so grateful for the impact that you both are having. I really appreciate you both for joining us and being so generous with your insights. I know I will be returning to this conversation.

South: Thank you so much.

Warford: Thank you. It was a pleasure to be here with all of you. [music]

Audio Information

© Copyright 2022 The Clinical Problem Solvers, Inc. All rights reserved.

Disclaimer: The CPSolvers provides information for educational purposes only. It is not intended to be medical advice.

View show notes for each episode at https://clinicalproblemsolving.com/antiracism-in-medicine/.

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