Building Equity

A pioneering, hands on health equity program challenges students to ask deep questions in pursuit of health justice.

As Emily Grilli ’19MPH and her fellow students stepped out of a van in the remote desert town of Sasabe, Ariz., on the morning of April 10, 2018, they were startled by an ominous buzzing.

It was a motion-detecting drone, and it was flying over their heads. It must have alerted law enforcement, because minutes later, along came an ICE border patrol SUV. But the SUV didn’t stop. Apparently, in their bright, clean summer clothes and sturdy shoes, the students didn’t look to ICE like people who might be crossing the desert illegally to enter the United States from Mexico.

Drone and ICE now gone, Grilli and six other students, their professor, a graduate assistant and a couple of tour guides resumed their task: to view a section of the now nearly 800-mile border wall that the United States is building across land that once belonged to the Tohono O’odham Nation. A photo taken by the graduate assistant captures the sight: The wall is a massive, dark, forbidding barrier snaking up and down undulating hills as far as the eye can see. On the same trip, the group would also witness the mass judicial processing of undocumented immigrants shackled together in a federal facility.

Grilli and her fellow students are among the first who will graduate with a Master’s of Public Health (MPH) in Health Equity. This trip to Arizona is one of several immersion experiences required for graduation.

But what does any of this have to do with health equity, or with a master’s in public health?

Grilli, who has a background in environmental education and conservation, and works for an environmental nonprofit in Boston, has a ready answer. “It is important not just to read about injustices,” she says. “You have to go out and experience them if you are going to work in health equity. You have to put your boots on the ground and interact with the people who live in the community every day. To be successful and effective in this work, you must work with, not on behalf of, the community. That is what our program is all about.”

Immersion trips like this one are not typical fare in MPH programs. But Simmons’ new program, launched in 2017, is anything but typical. Simmons is thought to be the first university to offer an MPH dedicated exclusively to the study of health equity.

The need for this focus was underscored by none other than Dr. Paul Farmer, co-founder of Partners in Health, the renowned organization that delivers medical care to the poorest of the poor around the world. “You are picking up the best part of public health from the 19th century and the 20th century by doing this,” Farmer told Provost and Senior Vice President Katie Conboy in a public forum when he was on campus in April of 2017. “Everybody who studies public health should be studying public health and equity.”

“Everybody who studies public health should be studying public health and equity.” —Dr. Paul Farmer, Partners in Health co-founder

Simmons’ 21-month MPH in Health Equity program mixes online academic learning with multiday, on-site immersion experiences. Student-designed practicums are the capstone of the curriculum, so graduates enter the field with hands-on experience in crafting and testing solutions to actual health equity problems in real-life settings. The program readies public health professionals to be agents of change in a world where too many people are deprived of the foundations for a healthy life.

Those foundations—jobs, housing, education, health care, safe environments, transportation, access to food—are known in the public-health field as “social determinants” to health. Their abundance or deficiency shapes mortality rates, life expectancy, maternal morbidity, rates of premature births, incidents of asthma and more. Health matters because individuals and communities with poorer health are less likely to reach their full potential, as are their children.

The unequal distribution of social determinants and resulting health inequalities is born of social structures, many of which have been influenced by racism, and you can see it in the data: According to the American Academy of Family Physicians, the life expectancy of black Americans is nearly four years less than that of white Americans. Black people in their 20s, 30s and 40s are more likely to be stricken with heart disease, stroke, diabetes and other conditions that typically occur at older ages in white people. Black people are seven to nine times more likely to die of HIV than white people. Health inequities also, of course, similarly afflict other marginalized populations.

Approaching public health through the lens of health equity is “an important tide-shift,” according to Assistant Professor Shelley White, a founder and the director of the MPH in Health Equity program. “For some time now, we have recognized that, based on your ZIP code, your gender, your race and ethnicity, your sexuality, we can predict how long you will live. And those patterns are generational,” she says. They are also political. The system advantages those with power over the more marginalized, White says, “We have to be asking deeper and more political questions if we really want to foster health for all. That is essentially what health equity is about: health justice.”

“Based on your ZIP code, your gender, your race and ethnicity, your sexuality, we can predict how long you will live. And those patterns are generational.” —Assistant Professor Shelley White

The program’s meat-and-potatoes academics are taught online. Half the course content is self-paced, with interactive features. The other half is taught in a live-session classroom: Students and professors can see and interact with each other in real time, engage in break-out sessions, participate in interactive polls and collectively write on whiteboards. The courses cover material that is required in national standards for MPH programs, but at Simmons, the content emphasizes health equity themes. For example, in his course on biostatistics, Assistant Professor John Quattrochi pulls from topics in LGBTQ health, or health across economic status in Rwanda, or studies in the implicit racial bias of physicians. “We try to cover multiple examples of how these sorts of rigorous, technical, epidemiological and statistical methods can be applied to questions that are at the forefront of the effort to promote health equity,” he says.

In addition to their coursework, students must participate in two immersion experiences. The first experience, a four-day weekend in Boston, happens about halfway through the first year. Students engage in “heads and hearts” learning. The “heads” part covers the history of racism and the systems and structures it built, and how that impacts health in Boston’s communities of color. The “hearts” part fosters introspective study and dialogue; students reflect on their own relationship to racism, the development of their own racial thinking and how racism influences their position in the world.

With their second immersion experience, students choose between spending a week in southern Arizona, or 10 days in Ecuador. The Arizona immersion takes them to the Patagonia desert region along the U.S.-Mexico border. There, they delve into the complexities of immigration and health by visiting migrant trails strewn with abandoned water bottles and backpacks, watching deportation court proceedings, speaking with humanitarian groups, seeing the consequences of environmental injustices and learning about the histories of Native Americans at the border. During the Ecuador immersion, which debuts in January of 2019, students will visit remote regions of the Andes and the Amazon to learn about rural health and the marginalization of indigenous peoples. Along the way, they’ll meet with women’s collectives, learn about traditional medicine from a shaman and visit agricultural learning centers for farmers.

“These trips allow students to deeply explore and critically analyze systems and structures that disadvantage populations, historically and today,” White says. That’s part of the head work. The heart work comes from “the opportunity to think about the concept of, and the importance of, cultural humility, and how that relates to developing a practice in health equity.” (As White explains it, “Cultural humility implies that one can never be culturally ‘competent,’ but instead must humbly engage in a lifelong process of reciprocal learning, critical self-reflection and advocacy to redress societal and structural power imbalances.”). Through this combination, as White explains, “when we bring together heads and hearts, students develop skills to mobilize as powerful change-makers for health equity.”

Students refine their skills through their Health Equity Change Projects—150-hour practicums they design themselves and implement within health centers and other nonprofit organizations. Students plan and execute their projects in a sequence of four courses: first, they identify a topic, develop goals and objectives and research potential organizational partners. Next, they narrow things down—they document a particular health inequity in their field of interest, identify the social determinants that are creating the inequity, propose a specific, measurable, achievable approach to addressing the problem and find an organization that will allow them to implement their proposal. Finally, they carry out their projects in public-health settings and submit for grading a digital portfolio describing their strategies and outcomes, and evaluating their work and its impact.

The first Health Equity Change Projects won’t be completed until spring of 2019, but even now, in their early planning stages, the projects are shaping up to cover a wide and interesting set of issues, like the environment and access to healthy spaces; access to mental health services by African-American teens in Roxbury, Mass.; maternal and child health in California; sex education for young African-American women; and access to clean water in Haiti.

A project by Maile Panerio-Langer ’19MPH will address the low rates of prenatal care and high rates of preterm births in Brockton, Mass., among immigrants from Cape Verde, Ecuador and Haiti. She’ll focus on the doctors and midwives at a neighborhood health clinic. “I’m looking at a different way to provide prenatal care in the hope that it will build trust and encourage women to come in and get care early,” she says. “Rather than go to [women] and say, ‘this is bad for you,’ we want the doctors to present something that is comfortable to them in their culture and ethnicity, and allow the patients to make informed decisions to be as healthy as they can.

“My project is really around health literacy,” she continues. “When I interviewed community members, I was told that the staff seems to be heavier on the whiter side the higher up you go, so how do we train physicians, how do we encourage them to make sure that what they are providing is culturally crafted and culturally humble?”

Panerio-Langer, who has a degree in psychology and once worked with at-risk youth, is president of HERE4Justice, a group founded by MPH students who wanted to do something about the things they were learning in their online classes. The mission of HERE4Justice is to pursue social justice and health equity through student learning and action. Members of HERE4Justice have conducted a campaign to raise awareness about gun violence, and Panerio-Langer was given the opportunity last April to attend a three-day conference with the MPH program director on strategies for health equity and community organizing with the Social Medicine Consortium in Gallup, N.M.

Assistant Professor Felipe Agudelo Acevedo, who oversees the development and implementation of the Health Equity Change Projects, meets students when they are in the last four terms of the MPH in Health Equity program, and they have been through a lot. They have received rigorous training in epidemiology, statistics and domestic and global political economy. They have studied theories of social justice and the structures that perpetuate inequality. They have learned about community-based research for health equity, health policy analysis and how to effect change. They are taking courses in public health leadership and management. They have seen with their own eyes what happens when people and communities are deprived of the social determinants of health. And they have expanded their worldviews while also facing the limitations of their personal perspectives.

For Agudelo, that has resulted in some intense conversations. One student, who is white and came from a place where social issues and inequality were rarely given much thought, got teary as she talked with him about her growing awareness of racism and inequality. Another student, a black woman from Africa, talked with him about not quite fitting in with the white students she had gone to college with, or the African-American students, either—another wrinkle in the dense puzzle of racism.

Agudelo emphasizes that these kinds of encounters are not only encouraged; they are intended by design. They are, indeed, essential because the purpose of Simmons’ MPH in Health Equity program is to educate public health professionals who are prepared to effect social change.

“You become an actor for change by listening,” Agudelo says. “To make structural changes in the social determinants of health, you need to acknowledge the individual and the community and be humble enough to listen to their story. We challenge our students to know and understand the living realities of those who are oppressed. You can’t inspire change unless you bring critical thinking skills and imagination, and you put yourself in someone else’s shoes.”

Arizona photographs by Luisiana Duarte ’18