Breaking barriers: Gender, health, and justice for all

0:00:43 Host: In our rapidly evolving society, gender equity remains a critical issue that impacts access to health care, quality of care and overall well being. Despite some progress, disparities persist that often adversely affect an individual's health outcomes. Gender is a core social determinant of health and one that requires enduring vigilance to ensure the healthiest people and communities possible. Across the US disjointed legislation codifies inequity through policies and laws in some states, while protecting equity in others. In today's episode of Population Healthy, we bring you a discussion between three experts on the topic of health and gender equity in the modern era. This conversation was originally part of a live event hosted by the School of Public Health. The moderator is Justin Colacino, and he'll be the first voice you hear. Colacino is an associate professor of Environmental Health Sciences and Nutritional Sciences at Michigan Public Health Health. The panelists, in order of their appearance, are Sari Reisner, Associate professor of Epidemiology at the University of Michigan School of Public Health Daphne Watkins, professor of Social Work at the University of Michigan, and Eli Savit, prosecuting Attorney of Washtenaw county, where the University of Michigan is based. Here's Justin Colacino to kick off the conversation.

0:02:01 Justin Colacino: So I'm just gonna ask each of you to just briefly introduce yourself, talk a little bit about your experience and expertise in the area of gender and health equity, and tell us a little bit about what drew you to this field and what keeps you in this work. Dr. Reisner, maybe you want to start.

0:02:17 Sari Reisner: Thank you so much for having me and us and for organizing this event. Really delighted that we're able to engage in dialogue and exchange, appropriate given the title of our series here. So yeah, so my name is Sari Reisner. My pronouns are he and him. I am a transgender population scientist. I was trained as a social and psychiatric epidemiologist. I'm deeply invested in transgender diverse health, also in sex and gender based research methods. So for example, how do we capture gender identity data, sex data, etcetera, and how do we have methods that are responsive to understanding both sex and gender as determinants of health and well being at the population level. I got to this work. I've always been a little bit obsessed with gender, I guess, but I got into public health kind of by accident. I started writing grants after I graduated from college and I realized, holy smokes, I'm doing public health and fell in love with it. So the idea of equity and the way that gender is associated with the patterns and distribution of diseases across populations and also well being and specifically gender and transgender experience. So that's what I...

0:03:34 SR: Thanks.

0:03:37 Daphne Watkins: That's me. Hi everyone, I'm Daphne Watkins again. And I think you asked how did we get into this work?

0:03:42 JC: Yeah, what brought you to the side?

0:03:45 DW: Yeah, yeah. Great. So for the past two decades, I have been doing work with and in service of black men. And specifically my work has focused on mental health, expanding definitions of manhood or masculinities in the plural sense, and then of course, social support. And so, yeah, I got into this work because I always tell my students their research search is me search. And it was me trying to search for understanding in myself and how I grew up, my relationships with my father, my brother, various black men in my life. And so, yeah, for me, it was really trying to pull the curtain back and understand exactly what is happening at the intersections of race and gender in particular, and what those experiences look like for black men in the United States. So thank you.

0:04:31 JC: Thanks so much. Mr. Savit.

0:04:33 Eli Savit: Okay? Yeah. So you probably all think that I'm lost here, but they did actually invite me to be on the panel. I had to double check despite not having a doctor in front of my name. And so I'm not a doctor. Juris Doctor doesn't count. Nobody thinks it does. I'm the prosecuting attorney for Washtenaw County. You might ask, what on earth does that have to do with health and health equity? Well, there's a couple of answers to that, and I'll say a little bit about my personal experience here beyond that. But the truth of the matter is that public health and crime are deeply, deeply interrelated. I am a prosecutor that does not particularly want to prosecute cases because once we are prosecuting cases, it means that a crime has already occurred and we are trying to minimize the damage that has already been done. And access to health and access to health care across demographic groups has been rigorously shown to decrease crime, to increase well being, and creates a virtuous cycle rather than, frankly, the un-virtuous cycle that we often see by cycling people in and out of jail, trying to get them treatment there, then they come back, then they're homeless, then they go back in jail.

0:05:45 ES: It's a much better way of dealing with things when you prevent it at the outset. So also, in addition to that, I have, somewhat surprisingly, during my term in office, had opportunities to litigate, or been forced to litigate actually, around certain issues pertaining to gender health equity in particular. Most prominent among those was, along with six other prosecutors from across the state, we litigated alongside Governor Whitmer to invalidate Michigan's archaic zombie abortion law that was scheduled to go into effect after the Dobbs decision. We have also led coalitions of prosecutors and other government officials on briefs, for example, supporting the expansion of Michigan's Elliot Larson Civil Rights act to LGBTQ people, in addition to leading a coalition of 81 cities, counties, and local officials from across the country seeking to ensure that decisions around gender affirming care for young people remain between kids, their families, and their doctors without state interference. That's some of the work that I've done, but there really is a profound connection between our day to day and health equity. I'm pleased to be here.

0:07:05 JC: Thank you so much. You can see our panel has very diverse expertise. I thank all of our registrants for providing questions as you are registering, I've done some work to try to coalesce these questions together. I'm going to ask the one that we certainly got the most to start. Given what we can consider a rapidly changing political landscape, how best can we keep gender equity and health focused work moving forward?

0:07:30 SR: Small question to start with. Yeah, I mean, I think we're in quite a time right now. Public health requires that we pivot quickly. I think certainly this time is keeping us on our feet. So the lens through which I think about transgender health is thinking about gender more broadly. And so I like to frame it in the sense that gender is a multidimensional construct. So there's gender identity, a felt sense of who you are and your gender, gender expression, how you do gender, gender roles. So thinking about these multiple dimensions and the ways that we do gender and sort of keeping that at the forefront, I also think that there's a clear scientific evidence base to be talking about that gender is a determinant of health. That is a factual statement. And I think from a scientific perspective, we can think about the ways that we can now show as researchers how gender shapes health. I can totally nerd out for a minute and talk about a directed acyclic graph in epidemiology. When we're talking about a DAG and it's a causal path diagram, if you are the executive administration and you say sex and gender are the same thing, then you have sex to your health outcome.

0:08:40 SR: But if you are all of us who are not, then you understand that sex goes to gender. And gender goes to health. And that is around. So, for example, help seeking behaviors. We know that trans people have negative experiences in care. Legacy of mistrust due to like the way that there's been a medicalization of trans people and bodies. So we know that avoidance of care and sort of suboptimal access to care is an issue that's very strong in the community. I think that we need to kind of make it very simple and think about like, what if we miss that pathway, that causal pathway to health, then what are we not seeing scientifically? And that is an intervention kind of point and thing that we need to think about and how we address that gender then will be sort of, I think, this multilevel piece. We have to think about the different levels of influence and how we attend to that. So that's like a small thing, but I'll stop there for now.

0:09:33 JC: Yeah, that's great.

0:09:34 DW: Yeah. So I think the question focused on what we should do and the first thing that popped in my mind was don't stop, I think keep going. And I'm going to put on my social work professor hat for just a second and think about the importance of organizing and how can we come together to strategize, to come up with, you know, tactics and strategy for how to proceed forward. I think sometimes our knee jerk reaction is to react, to sort of jump out there instead of really pulling back for a second and thinking, okay, what tools do I have at my disposal, you know, making sure that I'm going about it in a safe way and in what ways can I think about the long term. Because this is a long game. I just want to also speak to the students in the room for a second. We need you on the other side. And so it's very important to think about sustainability of energy, of time, of all of those things. Things too. So just be very thoughtful and intentional about all the moves that you make because again, we need you on the other side of this fight.

0:10:32 JC: Yeah, thank you.

0:10:33 ES: Don't be cowed by threats that don't have legal force behind them yet. That is what those that are making those threats want us to do. They want to ensure compliance. They want people to cower in Fear and to stop doing the important work that folks are doing. And look, there's a place for lawyers in this too, thankfully or unthankfully. And you've seen already a number of the directives coming out of Washington, DC be challenged in court by nonprofit groups, state attorneys generals and others. And a number of them have been frozen. And these are things that do carry legal threats with them. So, you know, look, if it goes up to the Supreme Court and the law is the law, I agree with Admiral Levine on that. We gotta follow the law. But until then, keep doing the work, keep showing up to work, keep fighting for what you believe in. Lawyers will be lawyering, all the while. And some of this stuff really is just about trying to change the vibes so that people feel afraid to do the important work that they should be doing. And if we just give in to that, they win without a fight.

0:11:51 ES: So keep doing the work is the most important thing that I can say and what I hope everybody in this field, in particular this crucial field, continues to do.

0:12:00 JC: What ways does gender identity influence mental health access and treatment? And what initiatives are really effective in improving outcomes? So maybe I'll throw this one to Dr. Watkins to start. Could you start us off and share some of your experience?

0:12:12 DW: Yeah, sure, sure. So we know that there are long standing systemic inequities in health care access and quality that disproportionately impact historically marginalized groups. I think that's what we all are here to try to unpack, particularly women and people of color. But I also want to highlight the unique challenges faced by black men in particular when it comes to mental health stigma. Because it's so important for us to think about what I like to call culturally sensitive, gender specific and age appropriate care. This is where we have to think about interventions specifically targeting certain groups. I want to duck in case the epidemiologists in the room want to throw tomatoes at me, because I'm going to talk specifically about why there is a place for that work and we need that work for those of us who want to do intervention. Sometimes you have to be a little bit more narrow in our focus as well. So I think there are things that we can be doing. There are a lot of folks right here on campus who are doing some really fantastic work around interventions. I'm just a little bit biased. But there is this program called the Young Black Men Masculinities and Mental Health Project, or YBMen for short, that specifically uses social media and actually in person Meetings as well, to promote mental health for black men and boys all across the country.

0:13:27 DW: We have a site in Australia, also have a site in Toronto, Canada. And so that's just an example of something that we see that's culturally sensitive, age specific and gender appropriate. And so I think it's very important for us to think about those nuances that we sometimes miss out on when it comes to actually making a difference and developing something that can actually make an impact beyond our research.

0:13:51 JC: That's fantastic. Any other thoughts about gender mental health impacts and where we've like really seen effective interventions?

0:14:00 SR: Yeah, I mean, I think when we think about gender responsiveness, you know, I think that's important in terms of trans community specifically. You know, I think that, you know, Dr. Levine said, for folks who wish to access and would like to access gender affirming care, that is life saving. That is a mental health issue intervention. If you look at the effects for the studies that we've seen, they're actually like on par with some of our other like, CBT type interventions that we would see, for example, to treat depression. So I would say that, you know, the other piece is like, for trans people, I think in terms of mental health, you know, there are experiences that are sort of shared stressors with other populations. So it could be things like, you know, poverty or, you know, cost, etcetera, certainly racism. In terms of thinking about intersectionality, there are also trans specific stressors. Those are the things that are driving disparities. And those can be things like, for example, transgender specific intimate partner violence. That's wielded specifically as a tactic by partners as about control around trans identity. So it's important to understand both and address those things specifically.

0:15:10 SR: You know, I will say on a personal note, like, as a person of trans experience, I feel like where we are right now in terms of mental health, it's a throwback. I transitioned in 1999 and we are like in a throwback right now. Like, I don't even know what is happening. So, you know, but I will say that, like, it's very difficult when sort of rights are taken away. Once you have rights, you know, it's very painful. In 1999, it wasn't the same thing. Everything was out of pocket. There was no insurance covering anything. There's very hard to find providers and all these kinds of things. So I don't wish that anybody go through that and we can go through that. You know, we could get through this. And I think that trans communities from a mental health Perspective, we really need to lean into each other right now. And we really need to lean into allies, too. Like, we really need to come together. So, you know, just share that as well.

0:15:56 JC: Yeah, thank you.

0:15:58 ES: The only thing I will add briefly to this discussion is just to circle back to the point I made in introduction, which is the intersection between mental health and future victimization of crime. Because what the data shows us is that those who have mental health issues are significantly more likely to be victims of crime. Transgender population is also independently significantly more likely to be victims of crime. So when we deny mental health interventions such as gender affirming care, but also just simply allow for discrimination in the health care system, we are exacerbating the risk for an already vulnerable community that they are going to become a victim of a crime, and a victim of a violent crime at that. So, again, the idea that denying health care doesn't have significant downstream consequences, we see the downstream consequences in the courts day in and day out. And it's, I think, an important point to emphasize that this is certainly about basic humanity, certainly about access to health care and all of that stuff, but mental health interventions that are available to everybody is also a public safety intervention.

0:17:20 JC: Yeah, I think that's really well said. As people were sort of like registering for this and gathering their thoughts. There was also a lot of concern amongst the community about how can we best protect and support the transgender and non-binary members of our community. And so maybe starting with Dr. Reisner on this one, what do you view as some of the most significant healthcare access barriers faced by transgender and non binary people? And are there strategies at the policy level or even at the grassroots level, you can see that help address these barriers?

0:17:48 SR: I mean, there are so many, you know, I think, certainly I mentioned. I mean, if you think about this in sort of multiple levels. The individual interpersonal and structural levels, you know, certainly, I think. And you know, even tying back to the mental health piece, you know, there is a legacy, as I mentioned before, of medicalization and sort of like the psychiatric part of gender identity being a mental health "diagnosis." Right. And the pushing back on that and the advocating for that to be moved and, you know, to think of this is more of a sort of medical issue. Or something that might be better addressed outside of psychiatry. You know, so I think when we're thinking about access barriers, trust is a major barrier. We can also think sort of interpersonally, you know, about sort of systems that are in place for people You know, so for example, like, you know, when we're even talking about access to gender affirming care, there's also, you know, people not having people to take care of them. Like aftercare or you know, community, you know, support, family support is a huge one.

0:18:46 SR: So you know, when we think about interpersonal processes like bullying or when we think about family support, you know, those things are protective. So and they're also very important for healthcare access. So you know, and then of course we have this larger policy context that we're working in. So I definitely don't have solutions. I will say that there are better data and I think that we need more information to really flood the current era of misinformation and disinformation with some good science as far as care access. One big thing is that suicide attempt rates and ideation rates are extremely high in trans communities. They were already high and I'm afraid that they're going to be higher. And I have a study that's a suicide prevention trial right now, testing and intervention to reduce suicide risk in 18 to 24 year old trans folks. And I'm using that word inclusively by the way. I think we need to find more solutions of what works. But we know that policies work. There was this great study at Human Nature Behavior that came out just at the end of 2024 by Lee and colleagues. And it was looking at states that introduced anti trans laws between 2018 and 2024.

0:20:01 SR: What they found is that the 13 to 17 year olds there was like an increase in the incidence of past year suicide by 7% to 72% depending on where they were comparing those who were in states that passed the law versus not. And then among 13 to 24s it was 25 to 27%. So we're talking about like a 25 to 27% increase, increase in incidence in this causal sort of design looking longitudinally in the time after the passing of a law, you know, so it's a very strong design and a very strong study to like show us that, you know, that the really negative impacts potentially causally, you know, that we can say. So I think we need to strengthen that piece right now. I could buy research app right now.

0:20:43 DW: I thought that was incredibly comprehensive. I have nothing to add.

0:20:49 JC: Ditto, very well said. I think people are also interested in policy from the other direction. So policies that we can use to protect and enhance health equity and really thinking about successful legislative approaches to do this. So maybe I'll start with Mr. Savit. On this one, could you tell us a little bit about how differences in local or state policy influence gender equity in health care? And then are there some examples which demonstrate particularly promising legislative approaches?

0:21:17 ES: Ooh, that's a 50 state survey type of question here. But look, I mean there's some obvious differences in states approach. And really I want to focus on the state level here because I do think that that's where primarily these types of policies are made. But let's start with the obvious one, right? You want to talk about gender equity and there's a bunch of states where reproductive care is illegal right? Now that is not a particularly good gender equity based approach in my view because people die when they are unable to access reproductive care. And you know, that's something that you've seen death, you've seen severe injury in states where abortion is criminalized, particularly where there is no exception for the health of the pregnant person. And you know, so I guess an obvious legislative approach is to legalize reproductive care in your state, just as it was for a half a century prior to the Dobbs decision. But beyond that, you know, states have a lot of leeway under relevant health care laws, including Medicaid, as to what they can require to be covered and not to be covered. You know, we talk about in the abortion context like the specter of a criminal law being brought down on somebody who engages in a health care choice.

0:22:50 ES: And you know, you're seeing that as well in the gender affirming care context for minors. But that's actually the exception. It's pretty rare with the exception of those two specific laws that you're going to like have a criminal law against a generally accepted medical practice. But that doesn't mean that care is available because you've got to have insurance coverage to be able to pay for it. So for example, even in Michigan, right, where we passed the reproductive Freedom for all initiative right to constitutionally lies the right to an abortion, all sorts of other reproductive care. It is still not yet the case that Medicaid in Michigan covers abortion. And Medicaid, of course, you know, is for lower income folks, which means that that is not care that's as readily available depending on A, of course sex, but also depending on socioeconomic status. Now that law is being challenged by the ACLU of Michigan. So maybe in a year's time this will be different. Beyond that, you know, a number of states do not cover fertility treatments through either Medicaid or by imposing requirements that private insurance cover fertility treatments; these are choices that a state can make.

0:24:04 ES: And in the states that, you know, frankly have covered the full panoply of choices that people might make respecting fertility with respect to reproductive rights, they have better outcomes. Because it's not just legal, but it's actually accessible. I can go on about this, but one thing I do want to flag in the current environment is that a lot of this is ultimately subject to federal preemption, which means that if the feds pass a law that prohibits states from making certain choices, that is preempted. And one thing that I am worried about in terms of, and I know you asked about good legislative choices and I keep talking about bad ones, but I'm worried about, okay, we made a good legislative choice recently in Michigan when we got rid of our Medicaid work requirements. That was blocked anyway by court and the Biden administration didn't put them into effect. But I'm worried because the Trump administration has announced that it intends to promote in states and perhaps require work requirements for Medicaid. This is not just in order to get certain types of care that is covered by Medicaid, it's whether you get health care insurance at all.

0:25:20 ES: And what we know about work requirements for Medicaid is that they do not work, they do not like, suddenly motivate people to go and get jobs. It's not like people are just like sitting at home. Oftentimes you may be a caregiver and you want to talk about gender equity, that is a burden that falls more heavily on women. And if you are a caregiver and you can't work, and because you are a caregiver, you are denied access to Medicaid, you are denied access to health insurance. The cascading effects really radiate outwards and they're going to land at the doorstep ultimately of prosecutors and judges, like me. Because healthy families are the best crime prevention tool that we have. Beyond that, I'll just say Medicaid work requirements are not in any way shape or form equitable. I actually did write this, okay. Maybe this is why you invited me to be up here. I actually did write a piece about this back in 2018 when Michigan was considering them. But if you look at places like Detroit and Flint, where there's lower, there's higher unemployment rates, fewer jobs available, and also you have to travel relatively long distances in order to get jobs and to look for work, and in a car dependent state like Michigan, you're raising the burden on people disproportionately black communities to find work.

0:26:42 ES: It's harder for them to do so, which is inequitable if you're going to be imposing this like supposedly neutral Medicaid work requirement. So there's a whole host of issues with that. So while there are a variety of good state approaches and bad state approaches, one thing to keep an eye on is federal preemption. What the federal government is going to be doing not just with work requirements, but with respect to so much else with Medicaid plans and its other hooks. That was a long answer. Sorry.

0:27:10 JC: That's what we were looking for was that perspective. I do have sort of like a follow up question as we're thinking about sort of like equity and access to care and health outcomes. And folks were really interested in learning more about intersectionality and how gender disparities in healthcare might intersect with race or socioeconomic status or other identity factors to reduce really compounded effects on health outcomes. I'm wondering if any of you can speak to your own work or what you've seen with respect to sort of like intersections across different identities.

0:27:38 DW: I can start. Yeah. And so I'm so glad you brought up intersectionality because I feel like I spend a lot of time in my classes trying to dispel the myths around intersectionality and how a lot of people think it's just the intersections of our various identities. You know, however number of we see ourselves as race, gender, income, whatever. But it's not that we know that there are systems and structures at play that use intersecting identities as a vehicle for oppression, for discrimination, for vulnerability. And so I think sometimes the systems conversation gets left off of our conversations about intersectionality because it's so much more than multiple identities. It's the systems at play that let us know that, hey, because of these multiple identities, now here are the things we're going to put onto you that's going to prevent you from succeeding in life, being healthy, accessing care, accessing judicial systems and things like that. But it's just so much bigger than that. And so that's why it's very difficult for me to think about just gender equity without thinking about other identities as well. Like, I think there's so many various intersections that it's hard for me to parse them out.

0:28:43 DW: And I'm sure others feel the same as well. But your question was exactly how can we think about that? Is that what it was? Okay. Well, the first thing that popped in my head, which I don't know if it's going to be a good answer or not. But the first thing that popped in my head was, I think it's so important for us to talk to so many people who don't look like us. Because we all go through life with various challenges, and sometimes we don't always acknowledge our privileges. And sometimes growing up or having various challenges as a young person, we tend to ascend to higher heights in life and still hold onto those challenges, not realizing that people actually see us as more privileged than we actually think that we are.

0:29:22 DW: And so it's so important for us to lean into. This is who I am. This is how I see myself. But let me talk to this person who's across the room who I would never talk to otherwise. Let me go introduce myself. Let me learn about their journey. Let me figure out exactly what's going on with them and why they're here, why they're passionate about their work. And it sounds so simple, but I can't tell you how infrequently this is done. You know, we tend to gravitate so much to people who look like us or who we think are similar to us. And so I think once we can kind of parse through all these different intersections and kind of understand whether we're aggregating or disaggregating them, I think that sort of unpacking process is a process that people often skip in this quest to understand intersectionality and how it actually plays out with the systems at play.

0:30:07 JC: Thanks, that's really well said. Any other thoughts from the panelists?

0:30:11 ES: Well, you asked if there was sort of example research.

0:30:13 JC: Yeah. Like maybe from.

0:30:15 SR: Yeah, yeah.

0:30:15 JC: From your own work?

0:30:16 SR: I don't know. I think. I mean, it's absolutely the systemic piece of this that is the vital part. And I was thinking of a study that we did called the Light Study with colleagues at Hopkins. And so we recruited an investigation, enrolled a cohort of trans women and trans feminine people, 1500 in the eastern and southern US the grant aims were really to look at HIV incidents and to explore vulnerabilities. And about a year into the cohort, what happened is we started hearing from word of mouth in our communities about high rates of death and mortality and people passing away. We have a community advisory board who, who were saying, you're talking to us about HIV. And we have a lot of other things going on, and this is not our primary thing that we're really interested in. And disproportionately we see the data that show that black and brown trans women and trans Feminine people have high rates of mortality. So anyway, we ended up pivoting our protocol a little bit to collect and ascertain deaths in the cohort. And so our primary findings paper was in the Lancet HIV that was both incidence rates and mortality rates showing differential risk for those who are trans women of color.

0:31:34 SR: And so the thing that I'm saying here is that the systems, as you were saying, of oppression are driving multiple health outcomes. It's not a single health outcome along the axes of both gender as well as race and ethnicity. And I should say racism. So anyway, that's just sort of an example. And I think that attending to that and bringing in community to tell us about this, because we wouldn't have asked that question like that wasn't the question we were asking. And so bringing in community to tell us this is the question we want you to answer, I think really can help expand what are intersectional questions that we might be able to explore further.

0:32:12 DW: I'll actually jump in. I'm going to go out of order here because something else popped in my head, but I was just sitting here thinking about how, you know, it's so important for us to evolve as researchers, as practitioners in our careers as professionals. Particularly because when I first started out doing work with and in service of black men, I thought about my own experiences and I said, okay, let me create interventions that's going to help black men. That's going to help black men. And then I feel like 20 years later, I'm looking at my work and thinking, they don't need the help. Like, we need to be trying to change the systems so that, you know, the systems now understand black men. And so by they don't need the help, I don't mean we shouldn't do anything. But I mean, sometimes in our training, we feel like we go, we get all this education, we have all this knowledge. We go to these communities of color, these marginalized groups, and we say, I'm here to help you. Not realizing that a lot of our energies need to be put towards the systems and the structures at play, because we don't need to change anything about them.

0:33:07 DW: There's nothing wrong with them. There's a lot wrong with the systems. And so I feel like this journey for me has been one of enlightenment and evolution and that man, not that I had it wrong back then, I think I did pretty good back then, but that I'm thankful for evolution and thought, and thought leadership around, you know, how does our work look over the course of our careers? Right. We choose a profession, we choose a topic to study. But then are we pivoting when the world pivots? When COVID-19 happens, how many of us pivoted? You know, when the racial reckoning of 2020 happened, how many of us pivoted? And sometimes we get so steadfast on. This is what I'm going to do. I want to be an expert in this. I'm committed to this. I'm doing my dissertation on this topic. So I can't change. Instead of realizing there has to be constant evolution in what we do, if we're really going to make the differences that we say we want to make on this world.

0:34:00 JC: I want to follow up on this a little bit. Thinking about the work that we do that's public facing and community engaged. I think that's something that all the panelists do a lot of really important work on. And if we're dealing with these complex issues, it takes interdisciplinary work. Between academics and legislatures, folks in government, public health professionals, community leaders. I was hoping that each of you could talk a little bit about your strategies to do this type of interdisciplinary, community driven work. And if there's like any lessons learned or recommendations for this, like next generation of public health professionals that you've taken away from doing this type of community engaged work.

0:34:36 DW: Okay, I'm fired up now, so I'm going to.

0:34:38 JC: Great, Excellent.

0:34:39 DW: Getting comfortable now. So I'm so glad you asked about the interdisciplinary piece because I sort of jokingly tell people I'm the queen of interdisciplinary work. Only because I have a PhD in public health. My undergraduate degree was in anthropology. When I came here to Michigan to do a postdoc, it was in social psychology. I had a faculty appointment in psychiatry and I'm a professor in the school of Social Work. And I'll say, I remember when I started this journey to really commit my career to helping black men doing work with and in service of black men. I remember telling people I want to be the expert in black men's mental health, period. I don't want to be the expert in social work or psychology or public health. Like, I want to read everything there is to know about this topic. And I think sometimes as educators, we sometimes, you know, tell our students, well, you know, you're a public health student, you're a social work student. Make sure you study all the literature in our discipline. And that's exactly the opposite of what I tell my students. Like, if you really want to know a topic, read everything there is to know on that topic.

0:35:43 DW: Because that way you can be bilingual, trilingual, you can talk across different disciplines and fields, you can go to conferences, you can write in different journals. And I think that sometimes is missed in our training programs. The importance of we have to be able to sit at the same table with people who were not trained like we were. And how else are we going to have an open mind and be receptive of what they have to offer unless we really value and respect what they have to offer? And so that approach was definitely met with a lot of opposition. But I think for me it was so much about just making sure that I made a difference in whatever room I stepped into. And so of course there was a little bit of career identity. People didn't know who I was. Are you a psychologist? Are you a public health professional? But instead of focusing on who I was, I told them what I did. And that opened up the conversation in ways that me saying, I'm a public health student, I'm a social work professor, whatever the case may be, that opened up the conversation in ways that I don't think I ever could have. If I told them who I was.

0:36:48 ES: I loved all that. And you know, I'll offer a perspective sort of from on the ground in my day to day work and our day to day work in the prosecutor's office. One of the things that I ran on is that we need to be treating a lot of stuff less like a criminal issue that requires punishment and more like a health issue that requires treatment and rehabilitation. And by that I mean we can throw somebody in jail for a lower level offense for 30 days or something like that. But if it was a mental health issue or a substance use issue that got them into there that place in the first place, if we haven't addressed that core issue, they're going to be right back out, probably doing it again, and we're going to send them to jail again and then we're going to, you know, it's going to lead to housing instability and work instability and then they're going to be even more desperate and the cycle is just going to continue and possibly exacerbate. So I believe that for a whole host of stuff we do better, both from a fairness perspective and from a public safety perspective at trying to get somebody help and resources and requiring as accountability. If you've got a mental health issue, you've got to participate in a program, you've got a substance use issue, you've got to do the hard work towards recovery. And if we do that and they're successful at it.

0:38:10 ES: What do we got to impose punishment for? Haven't we done our job? But I got to say, like, this is a thing that is... It's not like I made it up. It's been said multiple times by many, many people over the years. When you talk about the failures of the war on drugs and the like, we said we should be treating this more like a health issue and not like a criminal issue. And I agree with that. But also when you say we, who's we? I can't treat anything like a health issue. Like, again, I'm surprised to even be up here. I don't have a doctor in front of my name. Like, I'm a lawyer. You don't want me doing anything related to physical health or mental health. I'm just not trained for it. So that's where we need to have these conversations and build these partnerships. And so we have a really close working relationship with, for example, community mental health here and various substance use service providers as well as our law enforcement partners like the sheriff's office. We have a program here now called the Law Enforcement Assisted Diversion and Deflection Program, where for lower level offenses, law enforcement enforcement on the ground can refer somebody to behavioral health intake.

0:39:18 ES: And that's all that's demanded is they go to that initial intake session. And if you do that, we won't bring the criminal charges. And these are folks oftentimes that have been in and out of jail hundreds of times. I mean, like, I'm not, I'm not exaggerating here hundreds of times. And that simple intervention to say all we're asking you to do is go to this intake appointment with a caseworker can actually be transformative. And this stuff works too. I mean, we have partnerships again with providers of mental health substance use services, and we allow people to go through those services without even pleading guilty to a crime. And if they complete it successfully, case is totally dismissed. We got this program. It's called our pre plea diversion program. And you know what? You know what the recidivism rate is for that? You guys aren't going to believe me when I tell you for people that successfully complete the program, it's zero percent. Wow. It's not going to stay zero percent forever. But like it is now. So I'm going to keep bragging about it for some time, but when I say bragging about it, we need...

0:40:18 ES: All we did was take a step back and we needed to have the conversations and listen to providers and try to secure funding so that folks had a place to go outside the criminal system. That's a type of interdisciplinary work. Not just that facilitates better conversations, but that really changes lives because you can't rely on the government, you can't rely on the courts, you can't rely on the justice system, you can't even rely on providers to do it alone. We've all got to be working together from the same playbook, bringing our own individual expertise to bear.

0:40:51 JC: I think that's really well said and really like highlights the strength of all of us working together together on these complex issues. I think that might be where we leave it today. I think it's really, really good place to end it. So please help me thank our panelists for outstanding discussion. Very inspirational.

0:41:16 Host: Thanks for listening to this episode of Population Healthy from the University of Michigan School of Public Health. We're glad you decided to join us and hope you learned something that will help you improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, Apple Podcasts, Google Play, Stitcher, Spotify, or wherever you listen to podcasts. Be sure to follow us @umichsph on Twitter, Instagram and Facebook so you can share your perspectives on the issues we discuss. Learn more from Michigan public health experts and share episodes of the podcast with your friends on social media. You're invited to subscribe to our weekly newsletter to get the latest research, news and analysis from the University of Michigan School of Public Health. Visit publichealth.umich.edu/news/newsletter to sign up. You can also check out the show Notes on our website population-healthy.com for more resources on the topics discussed in this episode. We hope you can join us for our next edition where we'll dig in further to public health topics that affect all of us at a population level.