Family Matters, Community Matters: Challenging Opportunities in Public Health Practice

Rohan Jeremiah, MPH ’06

Associate Professor of Human Development and Nurse Science, College of Nursing, University of Illinois at Chicago

March 27, 2020

This article was published before the name of the Department of Health Behavior & Health Education changed to the Department of Health Behavior & Health Equity. Learn more about this change.

Public health does its best work when it remembers the vitality of communities and the importance of understanding and translating culture.

My research lies at the unusual intersection of trauma, HIV/AIDS, and substance use. My introduction to this intersection emerged when I was a Peace Corps volunteer in South Africa. My assignment began just after the fall of apartheid, and as the country’s economy and social energy were opening up to the rest of the world, HIV was spreading rapidly. Wherever I went, I saw the effects of the disease. Every weekend meant another funeral for a young person who had died.

In South Africa, funerals are a community event. There is a cultural expectation that you make time for this event, even if you did not know the individual personally. When I would ask how the individual died, the recurrent narrative was: “they just woke up one day and were sick and then didn’t make it.” Eventually, I realized “just getting sick” was a kind of code language for HIV. Eventually, in some contexts, some of the stigmas changed, and people were able to say “this person had HIV/AIDS.” But we still had a lot of work to do.

At the time, most HIV/AIDS education and prevention work was geared toward women and children because they were disproportionally affected. As a Community and School Resource volunteer working with community members, the exclusion of men struck me as problematic. Sure enough, men—particularly young adult men—in the community would ask why they weren’t being engaged to the same degree as the women and children.

Unexpected Estrangement

In South Africa, the formation of family embodies much cultural, social, and economic significance. Family decisions are made collectively between husband and wife and also extended family members. Focusing only on women and children to promote HIV/AIDS prevention and intervention, and ignoring the role of men in this process, was disruptive to South African norms. In particular, if a married woman was educated to protect herself by demanding the use of condoms, her husband would become suspicious. The outcome of this imbalanced health promotion was a power imbalance within the family structure that incited violence. Consequently, I believe the risks of domestic violence increased exponentially as a result of these public health practices that were not culturally grounded. These emerging revelations haunted the early years of my public health career.

When I returned to the US and began my doctoral program, I had the opportunity to go to the Caribbean. My dissertation research intentions were to look at reproductive health practices and services among Caribbean men. But once I got there, I realized domestic violence was a public health concern that needed to be addressed. The United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) recently developed a culturally-adapted domestic violence diversion program, Partnership for Peace, for the Eastern Caribbean. I was invited to join the steering committee of this program as an evaluator—assessing the fidelity and impact of the program.

My connection to the Caribbean is personal. My parents are from Grenada and migrated to the US in the 1960s. My initial reaction to the UN Women’s invitation was that it would take me too far away from my intended research interests. But after much reflection and getting to understand this intervention that focused on men and domestic violence, I saw how reproductive health matters also intersected with this program. My familiarity with Caribbean culture would help open doors to consider such relationships in this project. It was also a serendipitous opportunity to get back to the public health issue of domestic violence that I saw in South Africa.

Root Causes

Men were in the Partnership for Peace Program because they were accused of domestic violence. But when we looked closely to understand why this was so pervasive, the social determinants of violence—poverty, education level, unemployment, and adverse childhood experiences—were clearly central to the fundamental causes of domestic violence. In many cases, domestic violence was not a moral shortcoming of individual men in the community but a symptom of system failures.

Furthermore, we could see that children are at risk too—when they were exposed to their parents being violent. Eventually, they too, in many cases, would adopt violent tendencies as a way of dealing with conflict. Beyond holding Caribbean men accountable for their actions, the Partnership for Peace intervention had far reaching effects. Importantly, it revealed the need for implementing conflict resolution training into school curriculums that focused on teaching negotiation and other alternatives to violence in solving disputes among adolescents and young adults.

Trauma is an undercurrent to all of this domestic violence research. For children who witness domestic violence, trauma has lasting effects. Exposure to trauma increases an individual’s risk of engaging in risky behaviors and shortens their life expectancy. It can even keep you on the edges of your social circles—impacting your ability to access care and to go about your daily life in safe ways.

Navigating Social and Cultural Norms

During my time in the Caribbean, I also worked with the LGBTQ community, which is primarily underground due to archaic laws that persecute individuals who identify as LGBTQ. For this reason, gay men and women are constantly navigating their identities between the cultural expectations of getting married and having children but also undergoing clandestine practices to stay connected to other LGBTQ individuals. Such realities create a burden and incite more risk for LGBTQ individuals.

In Chicago, as discovered in the UIC Integrated PASEO study, it is surprisingly similar for racial/ethnic sexual-gender-minority community members. Chicago is known as an LGBTQ-friendly city, but our in-depth analysis focusing on the intersectional realities of racial/ethnic sexual-gender-minority young adults—particularly Black/African-American and Latinx—showed that they too face unique challenges.

Our findings were that racial/ethnic sexual-gender-minority young adults did not always feel welcomed in many of Chicago’s well-known LGBTQ-friendly establishments. Boystown on the Northside of Chicago, for example, is quite affluent and still relatively white. If they can’t afford to live in Boystown or are unable to navigate the overt and subvert discriminatory practices, racial/ethnic sexual-gender-minority young adults created other spaces or lived independently without a sense of community.

When you can’t integrate into those resource-filled, gay-friendly spaces or access their services, racial/ethnic sexual-gender-minority young adults are prone to increased risk of exposure—substance use, domestic violence, mental health concerns, and risky sexual behaviors, including transactional sex.

Most of my LGBTQ research activities are on Chicago’s Southside and Westside, home to many racially, ethnically, and economically diverse neighborhoods. Before the PASEO study, if racial/ethnic sexual-gender-minority young adults from these neighborhoods needed access to LGBTQ-affirming health care services, it would require that they travel for an hour or more to get to those resources on Chicago’s Northside. Once they got there, the health care services and resources would not reflect their lived experiences. As a result, many would opt out of seeking health care at all.

The PASEO project was federally funded by the Center for Substance Abuse Prevention program in the Substance Abuse and Mental Health Services Administration (SAMHSA). The goal was to develop and implement prevention services with a community-based organization—Chicago’s Puerto Rican Cultural Center—for minority young adults on the University of Illinois-Chicago campus and in Chicago neighborhoods near campus. Our services streamlined on- and off-campus, including undisclosed testing sites for privacy. We made referrals to clinical care and implemented evidence-based interventions focused on self-improvement, identifying positive attributes, and empowering racial/ethnic sexual-gender-minority young adults with education so they could make healthy decisions going forward.

The Power of Community

I used the word “underground” earlier to describe how LGBTQ people in the Caribbean have to live. But many of them are quite visible in their communities. LGBTQ individuals navigate their identities to access health care resources that respect their privacy and confidentiality. My work in the Caribbean has been to ensure that educational resources are available to everyone and that health care services and community organizations can maintain the capacity to deliver such important services for this underserved community.

The community is the driving force behind my global public health activities. We cannot always see the impact right away, but it is the engagement and advocacy for and on behalf of marginalized, vulnerable, and invisible people that are so critical for me. Part of that impact for me, as someone working primarily in academia, is to integrate my experiences into the classroom to illustrate the value of public health practice for the next generation of public health practitioners. Sharing stories can make a huge difference in how our students understand the values of public health.

This includes taking the time to facilitate opportunities for students to engage in new communities and to have intercultural experiences. Hands-on public health practice opportunities teach them how to navigate and work through differences and draw on their own stories for empathy. This is how I learned to do public health, and I see tremendous value in training future public health professionals with a deep appreciation of community engagement so that they have deep understandings of the communities they are serving.

Giving Back

A great model for this type of training at Michigan Public Health is the Public Health Action Support Team (PHAST), which deploys public health students around the state, nation, and globe to assist with various public health projects.

I was, in fact, a founding student member of the program back in 2005. I still remember sitting in a student lounge at the school with other eager students seeking ways to augment our classroom experience with field-based experiences. It’s exciting to see now—15 years later—how PHAST has grown into a truly global force and model of public health practice success.

And I continue to do my collaborative work with and through PHAST. My role now is coordinating activities in the Caribbean, particularly in Grenada. During my doctoral studies, I was based in Grenada, doing public health work and also on faculty at Saint George’s University School of Medicine. I built relationships with community organizations, and those partners today help us facilitate opportunities for students to work with those organizations and with the local government units.

The impact of PHAST’s work in Grenada has been significant across the country and extends across the Eastern Caribbean. With the energy and growing expertise of our students, we can work with units in social services, education, disaster preparedness and response, and family planning to develop surveys, improve community engagement and data collection, assist with data analysis, and develop strategic plans and evaluation projects. Many of these organizations are resource constrained and cannot make these elements of their daily operations. Yet data analysis remains vital to any operation that serves the health needs of a populations. We help them with developing these projects as a way to build a case for why they should be funded for the services.

Whenever we can spend a week or two with our partners, we focus on that backlog of community outreach and research they need to get done. Sometimes they’ve been waiting for years to do certain projects. A recent example of work, PHAST contributed significantly to the revision of Grenada’s Nationals Schools’ Policy on Drugs. Our students helped with the groundwork of getting community perspectives through surveys, focus groups, and interviews. In 2018, the policy became law and has been adopted as a model of excellence throughout the Caribbean. It will be used as a template for 19 other countries to revise and implement a similar policy.

A small group of energetic PHAST students that have some public health training can have a tremendous impact. Meanwhile, staff in the School of Public Health, its Office of Student Affairs, and its Office of Global Health Program stay engaged with our partners to keep projects moving, finish up reports, share data that comes in, and make sure all kinds of logistical matters are tended to.

Too many global public health researchers drop in for their data and then leave. PHAST is debunking that practice by maintaining relationships, providing continuity for projects between student cohorts, and having a global and sustainable impact. We succeed at doing this by matching UMSPH student skills with the needs of community partners.

For many PHAST students, these experiences are one of their first introductions to intercultural work. The invaluable insights and skills they gain here will help them understand and translate the many other cultures they will engage as public health professionals.

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