Healing Flint through community partnership

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00:04 Narrator: In 1960, the population of Flint, Michigan was nearly 200,000 people. It was a center of American manufacturing and economic prosperity. Powering GM and others was an influx of new workers, black Americans looking for employment during a period known as the Great Migration. For a time, the city enjoyed the upward momentum of the post-World War II economic boom, but in the decades that followed, manufacturers abandoned their Flint operations. Many white families left for the suburbs. This white flight created a segregated city along racial and economic lines.

00:38 Narrator: With jobs disappearing and the population shrinking, the now majority black city was in a state of economic decline. Crime rose and the political voices and financial mobility of Flint's residents began to erode. By the early 2000s, the city of Flint was in debt. In 2011, then Governor Rick Snyder appointed an emergency manager. This government official had the authority to override decisions made by Flint City Council and Mayor in the interest of reducing the city's debt. In 2014, in an effort to cut costs, the city switched its long-standing water supply from the Detroit Water Department to the nearby Flint River. The water was not properly treated and a public health crisis erupted.

01:21 Narrator: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. In this season of Population Healthy, we’ll examine health inequities through the lens of race in America by talking to public health researchers, experts, and others to learn more about what can be done to work towards health equity in our communities and across our county. Dr. Pamela Pugh, a graduate of the University of Michigan School of Public Health, began serving as Flint's Chief Public Health Officer in 2016.

01:58 Pamela Pugh: From October of 2016 until December of 2019. I served as the Chief Public Health Advisor for the City of Flint, and I currently am an elected member of the State Board of Education, and I serve as the Vice President of the Michigan State Board of Education. And I think we have to go back to the beginning when the water was switched and you had residents that first said, hey, this is not a good idea to go to the Flint River water off of a water system that we've been on for years, decades, and that was the Detroit Water System. And doing it in haste, there were some concerns that residents had with losing their local control, and so they voted against that.

02:44 Pugh: Somehow, even though they voted down state takeovers, Governor Snyder was still able to implement an even stronger version of Emergency Management System, which took the residents' power. And then, you had residents who saw brown water, they saw rashes on themselves or their children, they smelled the water, the water did not taste right, but they were told to ignore all of that evidence and it wasn't until Dr. Mona Hanna-Attisha, also a graduate of the University of Michigan, came forward with actual data that substantiated what the residents already knew. It wasn't just lead poisoning, the whole water system was thrown out of balance, and so there was Legionella and Legionnaires disease and people died.

03:31 Pugh: You also had the erosion of trust, that's even more difficult. While their residents are looking to get their infrastructure restored, that trust is just as important to be restored, or more important as we talk about the physical health, the mental health as well as of the water system itself, that's still under repair. When you look at voices being just totally ignored, votes being totally ignored, you have a people, one of the most impoverished communities, and a mostly black and brown community, that felt their lives and rightfully so, were not valued.

04:15 Pugh: So that is the way that the residents felt then and continue to feel, and now we have another pandemic, where they are one of the worst-hit communities. When I look at how the pandemic, how it's being handled by this government, it's so reminiscent to me of the Flint water crisis. I recall a time when the state no longer wanted to issue bottled water, and I was called into a meeting at the Flint Community Schools and I was asked to sign off on the bottled water being removed from the schools, because if the bottled water was removed from the schools, then it could be removed from the rest of the city.

05:02 Pugh: There were no laws that would have required anyone to go into those schools and monitor once we were done. And then the other piece was making sure people trusted the water. We had a summer, I think it was summer of 2016, where we looked at some filters that had been put in place at the schools and there was bacteria growth that could have been opportunistic pathogens that could cause illness in and of itself. We were thinking holistically versus that, hey, it's time, that the time has run out and now we need to just be done with this crisis because we've gotta get on to other business.

05:41 Pugh: When we look at the residents of Flint, when we look at the residents across the state, parents, children, teachers, if we're not prioritizing the physical health of our children, of our frontline workers, then we're always going to fall behind, just as we are right now in this rush to reopen schools, we have some of the same concerns. Have schools been told to make sure that the kids aren't coming back to lead-tainted water or water that doesn't have enough disinfectant. There's so much that educators are having to think about, and that's not what they were trained to do.

06:20 Pugh: We can compare these two crises, one that was specific to a city and one that the whole world knows about, and because the whole world knows about the coronavirus pandemic, you have a little bit more pressure applied, you have more public health officials that are able to speak out, but in Flint, there were just a few of us who were able to speak out and trying to make sure that their voices were being able to be heard against a message that we should be done by now.

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06:55 Pugh: You have to take aggressive and bold actions to break up those systems of racism. There are racist acts that are taking place right now, there are people who have high positions that are making decisions that are based on racism, there's a system in this country that was built on racism. And so to break those systems up in and of itself, even if you didn't have racist acts, it takes aggressive, bold leadership calling it out, that gives me hope, setting up bodies that will address racism as a crisis, as an epidemic, as a pandemic, that gives me hope.

07:44 Pugh: But I will tell you, talk about undoing systems of racism, let's talk about adequately funding schools so that there's heat in the winter, there's air conditioning in the summer, you have buildings where the windows actually open and close, water that's not tainted and polluted. When it gets to those tough discussions, and you start talking about where the resources are, that is where I give pause to hope. I am yet hopeful. There's just a lot of work that needs to be done. 

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08:25 Narrator: Flint's challenges are both commonplace and uniquely its own. Dr. Kent Key is a lifelong resident of the city. He works towards solving Flint's challenges, and does so by including community voices and considering racial equity at every step.

08:40 Kent Key: So I got introduced to Public Health Start, learning about health disparities and how people who look like me and who lived in Flint, in communities that I lived in, were dying unnecessarily from things that were totally preventable. Communities that look like mine, you saw more people that were diabetic, had heart disease, had many of these common health disparities, and I didn't know that they were disparities at that time. I also noticed that there seemed to be patterns in certain communities. You'll see like a Family Dollar or a Dollar General next to a laundrymat across from a liquor store, kitty-corner to a church, kind of next door to a pay-day lending type of place, but you didn't necessarily see that in the suburbs or in the more affluent areas. I even remember asking an adult, why do they call them liquor stores where we live but party stores in other areas.

09:33 Key: So just, those were some of the subtle things that I'd noticed. A lot of the same patterns are still the same, like literally, I do a lot of national speaking about the Flint water crisis, and when I go into these spaces, oftentimes I ask students or audiences to close their eyes and then I will literally just name off the things that I named to you, the dollar store next to the fried chicken place across the street from the laundrymat, this visual, and then I ask people to raise the hand and tell me where they are. And they'll say, oh, Detroit, Chicago, South Side, Compton, Brooklyn, like these patterns I notice existed over time.

010:12 Key: That's when I believe the national campaign where Place Matters came out and where they were saying how even there's a disparity in life expectancy amongst zip codes, and how in some zip codes, you can literally be two blocks away, but your life expectancy is better, and how place matters. And when we start looking at maps and kind of overlaying many of the things I was sharing with you previously, we would see that those areas that had the higher disparities of... The lower life expectancies had those higher concentrations of those fast food areas, of those predatory types of systems that kind of led to systemic discrimination that we see playing out in so many ways, even today.

10:56 Key: And in Flint with the divestment of the automotive industry, like many rustbelt cities, it really impacted the overall economy, from quality education in the school systems to the upkeep of neighborhoods. And then you have people, I call it the great exodus, people moving out of Flint to other states trying to find employment, because we know, we had the great migration to the North, where people came from the South to get stable employment. And so when that employment left, a lot of the population left, and that also increases flight and abandoned homes and so many other things.

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11:38 Key: Currently in my work as a health disparities researcher, I use community engagement approaches to doing research. And what that means is, unlike traditional research, actually bringing community members and leaders to the table to decide and to design what the research should look like. And we know in traditional research, that's not normally the case, that it happens in the ivory tower until you need recruitment and then you come into the community, you get your data and then you back off to the ivory tower, and maybe not ever to return to the same community that you work with. But in community engaged research, it's really about building social capital and building trusted relationships with community.

12:18 Key: I've been working a lot on just health disparities across the board, and how do we engage community and create equity at the table, how is there a win-win, how do we ensure there are community level ethics protections. When we think about community engagement and community-engaged research, it shifts the whole notion of power and equity. There are two levels of experts here in this exchange, the researchers may understand research methodology, research protocol, and be experts in that, but community members know what works in their community. Even something as simple as where to host your focus groups. If you want to get as many participants as possible, there are certain times you just don't do it in certain communities. Because you have to take into account people's belief systems, people’s religious beliefs, culture, historical experiences that shape how people view engaging in research and how people view priorities, period.

13:20 Key: There are avenues now to engage communities in a more equitable way, and that equity goes not just with expertise, but it also goes with the decision-making, the co-ownership of the data, because whatever comes from the research, just like it's going to benefit the researcher with publications and their ability to use that data to write another grant to even expound on that work, so they're building a career off of this, that data should also be co-owned by the community, so that community now can use that exact same data and it can actually drive the creation and the development of programs that are sustainable in the community.

14:01 Key: And so that local CBOs and local faith organizations can use that data to create local programming based upon that exact same research data. So there needs to be equity in the win-win. And so community-engaged research allows us to do that, it allows us to engage community in such a way that when the community is engaged and have an equitable seat alongside their counterpart in the institution, number one, it creates more buy-in from the broader community. It will help alleviate issues around mistrust, because Ms. Johnson up the street may not trust Dr. Key in the institution, if she don't know him, but if Ms. Smith, who's a good friend of her, is on that research committee, she may be more willing to do it based on the social capital that she has with Ms. Smith.

14:53 Key: Because we have to understand, most communities of color have been historically misused by government and research industries. People always talk about Tuskegee, the research study that the United States Public Health Service did on black men in the South with syphilis. Even though they had the cure, they wanted to know what happened to the body in the different stages of syphilis, and many of those black men became ill, some passed away, some became blind, and it was very unethical and inhumane. These are experiences that African-Americans have, but there are several other studies that were just as devastating to Native Americans, to Hispanic Americans, to Asian Americans and to other minority groups. So we have to understand that there is a cultural and a historical resistance to engaging in research, and that's why we see minority populations mostly under-represented in our studies in public health and in medicine, and that is why it's important that the community is there to actually drive that research agenda, 'cause that helps us to leverage some of those historical breaches, and at the same time ensure that we're doing it in the most culturally appropriate and competent way.

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16:13 Narrator: A particular concern is the city's youth: Where does all of this leave them? How do young people in Flint become empowered when facing these disparities and such ingrained challenges? Dr. Cleopatra Caldwell is a Professor of Health Behavior and Health Education at the University of Michigan School of Public Health. Her work seeks to strengthen the bonds between black fathers and sons by reducing negative health behaviors and promoting positive health outcomes. In part, this project has given participants tools to face these challenges and dismantle some of the barriers in their lives.

16:46 Cleopatra Caldwell: I'm someone who really has a strong interest in adolescence as a stage of development specifically, and I also oversee a number of research projects that involve adolescence. There is a process called Youth Participatory Action Research, YPAR, and when you're taking it from that perspective, you actually work with the youth to understand from their perspective what are some of the issues and what are some of the solutions. We've used this concept specifically in the work that we've been doing with the Flint water crisis. There we have engaged youth in a project where we started off with community forums just to get their perspective in terms of what was happening to the community and to them personally, when the Flint water crisis happened.

17:30 Caldwell: At the height of the crisis, most of the attention, media attention, community attention, focused on infants, pregnant women, the elderly and adults, and oftentimes the voice of the youth was missing. So in this project, one of the things that we were able to do was to hold community forums with about 66 youth in the Flint community, and we were fascinated with some of the profound thoughts that they provided about the circumstances and situations they were facing. One of the things that resonates with us, even to this day, is the fact that because of what was happening in Flint. Flint historically has had some challenges economically with violence, and then the Flint water crisis was an additional assault on the community, if you will.

18:13 Caldwell: We worked with 13 to 17-year-olds. They were in a situation where when they told people they were from Flint, they could see the pity in the eyes of people, because they were figuring they would never get out of this community, they won't have any opportunities, they were going to be limited, and they were interested in doing something about that. They had experienced the rashes that some people had, they knew some of their family members that had challenges in terms of trying to get their pipes replaced, and they felt helpless. This was the time when social media had taken over and started showing all of the shooting of black males in many different cities around the country, in many different formats, even people walking away from police that were getting shot.

18:54 Caldwell: And we heard these youths sit there and say, we wanna do something, but we are afraid, because we're afraid that we will be harmed if we become activists, and that broke our hearts. So they felt that they lacked the power necessary to make changes. So we followed that study up with our YPAR study, and in this study, we were looking to engage youth in activities that would empower them. We wanted to look at it from an environmental social justice perspective, to teach them what it is to be an advocate for themselves. And in this case, looking at environmental social justice because of the water crisis, we wanted to engage them in activities that would empower them. So we developed a curriculum for the youth that would provide training about how do you do qualitative research so that you get the voices of people representative, how do you do quantitative research to begin to answer the questions that you have about these issues, and then how do you do soil testing, how do you do contaminated housing testing in order to be able to do something about these kinds of issues.

20:00 Caldwell: And then we help them develop Photovoice posters to be able to document in the community the experiences that they are having. In this project, we had several community partners work with us to go out with the youth in the community, and they spent three different weekends in the community collecting soil, collecting house particles, being able to take pictures of various, not only the challenges, but the strengths in the community. That's one of the most important parts of this community-based participatory process is it looks for strengths within the community and what can be done. So we then had a community forum for the youth where they presented their poster sessions to participants at that community forum, and they did a fantastic job.

20:46 Caldwell: One of the striking findings that came out of this is that 30% of the youth were interested in public health career as a result of this experience, and 40% of them still wanted to go to medical school, so that's a good thing as well. And then we also have 15% of them, I think it was, that wanted to do environmental health justice specifically. So it really exposed them in another kind of way, so instead of having the youth that we had the first time talking about, I'm not sure what I can do in the future, people have pity on me when they see me, we now have a group of 20 youth who are coming out saying, I can do this and I want to do this, and when the project ended, they were asking what can we do to continue it.

21:28 Caldwell: So we actually had a discussion with our steering committee in Flint to talk about engaging these youth particularly and in a Youth Action group that they have as a part of the American Public Health Association, as well as the local community. Our goal is to leave within the Flint community, this Community Action Steering Committee that's run by youth, that they are the ones that are determining what are the issues and how can we address them. The majority of the youth, as a result of this experience, felt very comfortable talking with decision-makers about what their concerns were and how they might be able to address them. So this is something that we are going to continue to work with.

22:06 Caldwell: One of the benefits of working with community partners is that whether or not we are there as the School of Public Health, the community is there, and they are willing to embrace these projects and adopt them so that they can become more institutionalized.

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22:26 Narrator: Dr. Marc Zimmerman is a professor of Health Behavior and Health Education at the University of Michigan School of Public Health. In partnership with Flint Community Schools, he examines the factors that promote positive outcomes for black youth in the city of Flint. This has paved the way for the development of new strategies for the city's youth to empower themselves in the face of increasingly difficult circumstances.

22:46 Marc Zimmerman: Resiliency theory is the idea that people overcome adversity to succeed. We want to think about what are some of the positive things that we could build up to increase people's chances that they would overcome risk, overcome adversity, overcome those things that they're faced with as children as they grow up, and that may get in their way of being "successful." Mentoring was one, and adult relationships, we found in the Flint Adolescent Study was very important for kids. Another thing we found was having pride in their identity as black Americans, having it central to their sense of self and having them having a positive view of themselves. Having a positive identity was actually also related to more positive outcomes for the kids in the Flint Adolescent Study.

23:31 Zimmerman: We saw all of this as ways to try to improve kids... Resources in kids' lives so that they could overcome this adversity. So that's what led us to creating the Youth Empowerment Solutions Program. And what we did there is we translated the results from the Flint Adolescent Study, we created a curriculum designed to basically help kids develop adult relationships and break down the adult/adolescent barrier where adults look at kids and see them as just a bag of problems, and kids look at adults and don't relate to them. We incorporated ethnic identity to help them develop a sense of pride and doing active learning around African heritage, like making masks and talking about what African masks are all about, learning about the history of African-Americans in the United States.

24:20 Zimmerman: And then we also incorporated this idea of them designing a program or project in the community that they would implement and own that would be theirs, hence the empowerment part. We said, let's create a program where they get to be part of the solution. We said, look, you guys are gonna go through this curriculum, and the idea is we want you to help develop community change that will improve peace and reduce violence in your community. They reported more conflict resolution, they reported being more empowered, feeling more in control in their lives, and they also reported less problem behaviors like drug use and delinquency, and more positive behaviors like staying in school and being more involved in community activities.

25:09 Zimmerman: We also looked at the streets around the sites where they did physical projects, like they did another community garden where they built a wall behind it out of wood and called it the Rosa Parks Garden, and on that wall, they put a mural. As we looked around those places and we said, what happened a crime before and after these things were up. What we found was crime went down, that there were fewer police incidents once this community project was up.

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25:38 Zimmerman: The water crisis was the tip of the iceberg. The issues that created that water crisis were under the surface for a very long time. It's something that we've been working on with our community partners, and certainly something that our community partners there have been living. So in a way, the water crisis was the culmination of the disparities of why that water crisis would happen there, and it would never have happened in Ann Arbor. If somebody in Ann Arbor held up water that said, look at my water, it looks like a glass of beer, 'cause that's literally what happened. It was dark tan water coming out of people's water pipes, and somebody else in Ann Arbor said, yeah, mine too, we would have gotten notice to stop drinking the water, something's wrong with it. That didn't occur in Flint. The idea of not being able to drink your water in America today, it's too shocking to think about.

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26:29 Key: The water crisis isn't over, and I say that on every interview, whether I'm locally or nationally, people across the country think it's over, 'cause it's not in the media. A little bit over 50% of the service lines in Flint have been replaced, and they don't call them service lines in the media, they say pipes, well, service lines are pipes, but they're the pipes that brings the water up to the house, but there is no provision for replacing people's in-home plumbing. Those are the pipes people are thinking that when they say pipes, that they're thinking about all of that. No, they're only replacing service lines.

27:02 Key: So if 50% of the population is below the poverty level, who has enough money laying around in an extra account to replace all the indoor plumbing in their home? These are things that the world don't understand it, that they're not aware of, because the lights and cameras are no longer here. Those of us who are here and who choose to remain here to build Flint back to where it needs to be, these are things that we fight for, and it's gonna take engaging these leaders in community-driven solutions. When you're a person like me, a black male, and you're in communities of color, you're tired of always having to bounce back. Some things you just shouldn't have to bounce back from. It's just like being a ball. If you're bouncing all the time, you're gonna get dizzy. We're tired and we're dizzy, but we're trying to recover and we're trying to get back to a place where solutions can happen, but they have to engage community, and it cannot be something that's dictated top down from the government.

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28:04 Narrator: On the next edition of Population Healthy.

28:07 Speaker: If we’re serious about our pursuits in public health, it’s absolutely necessary that we train a diverse workforce. Without it, we’ll fall short of our basic public health mission of achieving health and equity for all.

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28:57 Narrator: Thanks for listening to this episode of Population Healthy: Race, Inequity and Closing the Health Gap from the University of Michigan School of Public Health. We hope you learned something that will help you make the world a healthier place.

29:10 Narrator: Please subscribe or follow our podcast on Apple Podcasts, Google Play, Stitcher, Spotify, or wherever you listen to podcasts. Interested in studying public health with us? Join our interest list by going to our home page, publichealth.umich.edu, and check out our programs and degrees and other helpful resources across our website. Be sure to follow us @umichsph on Twitter, Instagram and Facebook to join the conversation, learn more from Michigan public health experts and share episodes of the podcast with your friends and followers. You can also check out the show notes on our website, publichealth.umich.edu/podcast for more resources about the topics discussed in this episode. If you want to stay up-to date with the latest research and expertise from Michigan Public Health, subscribe to our weekly newsletter, Population Healthy. Head to publichealth.umich.edu/news/newsletter to sign up, and be sure to join us next time. Thanks for listening and doing your part to make the world a healthier place for all.