[INTERVIEW]

[0:00:00.5] JW: Welcome to The Public Health Joy Podcast, the safe space for real and honest conversations about what it takes to transform public health research into life-changing solutions for our communities. I’m your host Dr. Joyee, a public health researcher, Ph.D. survivor, and entrepreneur.

In today’s episode, we’re talking with Dr. Dorothy Cilenti, about what it means to move upstream as we transform communities and systems in public health. This is the Joy ride you’ve been waiting for. Join us as we revolutionize public health through research, done with, for, and by our communities. Together, let’s create our Public Health Joy.

[INTERVIEW]

[0:00:56.2] JW: Welcome to another great episode of The Public Health Joy Podcast, and today, we have with us Dr. Dorothy Cilenti, who is the founder and CEO of Health Ascent Associates, LLC. Now, Dr. Dorothy has worked in local and state public health agencies in North Carolina for more than 20 years. She has managed large complex health organizations and has facilitated partnerships with numerous organizations, such as hospitals and health systems, community health centers, schools, faith-based organizations, and more.

Now, what I need to tell you is that Dorothy and I know each other because we are actually collaborators with WE Public Health, which is a public health collective consisting of 35 consultants, and growing, across the country, who are talented evaluators, trainers, strategists, thought partners, facilitators of research community advocates and creatives. I mean, you name it, we go it. 

At WE Public Health, we offer a wide range of quality consultant services such as technical assistance, training, facilitation, project design, and management evaluation, and all the things but most importantly, we share a common vision for justice and equity so we partner with our clients to walk hand in hand, bringing people first, compassion centered and evidence-based designs to amplify public health work. 

So, let’s get into it. Dorothy, go ahead and tell the people who you are and what you got going on.

[0:02:36.6] DC: Thank you, Dr. Washington. I’m really happy to be here and I am excited to be part of WE Public Health. I’m a new collaborator, just with the organization a little over a year. I have dabbled in private consulting work for some time. My day job is at the University of North Carolina Chapel Hill, where I work at the Gillings School of Global Public Health, primarily working with state and local communities to improve public health systems for maternal and child health populations.

So, that’s really my area of interest. I’m trained in public health and in social work with an emphasis on maternal and child health, and I’ve had just a great, long career, working with lots of amazing, talented, committed people, trying to leave the world a better place than when they entered it. So, we have lots of work to do but I’m really excited to be part of this group of consultants who are really motivated to improve our systems here in the US and abroad.

[0:03:43.9] JW: Yeah, and there are a couple of things that I loved about what you said. Number one, leaving a place better than we found it, and I’m – I am, the folks may or may not know but I was a girl scout, right? So, when we went to camp and we had to clean up, that’s always what they say, you leave a place better than you found it, and so in public health, that is such an important part of what we do. 

You know, we have come into so many challenges, challenges that we – I didn’t have nothing to do with. I didn’t bring these challenges, these problems but I’m here, and so I have a responsibility to contribute, to make this better than I found it, right? And then, even in your social work that ground, right? Public health and social work. I know for myself, I actually worked in the social work department as a public health professional. 

And those two fields are so interconnected, and you end up learning so much about the social workpiece and the public health piece and how we can not only impact our communities and individuals and families on kind of that front-line work, right? But also, how can we work upstream, right? Work with the policies, the systems because a lot of these problems and challenges are not on the individual level. It’s a systems-level thing, right?

[0:05:07.2] DC: Exactly, you’re exactly right, and I have found that there is a tension sometimes between the practice of social work and public health because social work is very focused on individual autonomy and self-determination and public health is focused more on what’s best for communities and populations of people, and sometimes that means giving up certain rights that we may think we have, like smoking in public places so that others are not harmed by our behaviors. 

So, I think we saw those kinds of tensions in many areas of public health when we were trying to regulate tobacco use in public places, and we know that as a society, we need to protect our children from second-hand smoke and we need to protect vulnerable adults from second-hand smoke. So, really, we need to be considerate and thoughtful about what we do as individuals because we’re a part of a bigger system as you said and we’re a part of a community, and we all impact each other’s well-being, and each other’s health through our actions and behaviors.

[0:06:16.7] JW: Yeah, and we kind of alluded to it, but I want to make sure that we have a clear definition and example, for those who may be listening. So, from your experience, can you explain kind of the concept of upstream versus downstream approaches to public health and how they differ, and what does that look like in actual practice?

[0:06:40.8] DC: I can and I can actually share the story that illustrated for me when I first started my training about the community, who is experiencing many fatalities from vehicles falling off of a cliff and ending up at the bottom and people being harmed or dying, and the ambulance having to come and take the people to the hospital or to the morgue, unfortunately, and these cars just kept falling. 

And then somebody said, “Well, how about looking at where the cars are coming off the cliff?” And so, somebody went a little bit further upstream and saw that this particular cliff was dangerous because there wasn’t a sufficient barrier between the edge of the cliff and the chasm below, and so transportation, now, transportation is a partner in public health, came and fixed the barrier, so that most people who are driving carefully and paying attention would be able to avoid falling off this cliff, into the chasm and you know, crashing the cars. 

So, they found that they have significant improvement and had much fewer accidents, having moved a little bit from the original scenario where there wasn’t the barrier to putting a barrier on the road so that people didn’t fall off the cliff but they were still finding that some people were still not navigating that curve very well, and so they went further upstream and decided, “Well, why don’t we just put some warning signs or some signage saying, ‘Curve ahead, slow down, 20 miles an hour.’” 

So, they went further upstream, looking at ways to educate the public. So, they used education and awareness to that potential danger, then they used some physical changes to the environment by putting in this barrier, and then they actually were able to see a decline in death and disability. So, that’s kind of my very concrete example of understanding the “Why’s” behind the health outcomes. 

The other example I’ll share is our iceberg model. Many of you know that phrase, “The tip of the iceberg.” So, the tip of the iceberg may be, I mentioned childhood asthma, it may be maternal deaths, it may be infant mortality, it may be injuries due to traffic accidents. It’s those events that we see at the top, and then we try to think about, “Well, why are those things happening?” So, we looked a little bit below the surface of the iceberg and we see these trends over time. 

So, when we were looking at traffic accidents, again, over time, we were seeing that they were increasing because there are more drivers, more cars on the road. So, why were these trends worsening? And so then, we looked a little bit below that and we looked at some of the structural issues, was it the design of the roadways? Was it that people weren’t wearing their seatbelts? Was it that there are young kids who are learning to drive when they were too young and they needed a graduated license program? 

So, understanding the events, looking at trends over time because many things are rare events and so, you need to look over the course over a number of years, see, you know, is this a worsening trend? Is this a flat line, is this improving? And then looking below that, what are some of the structural issues that may be impacting those trends in the environment, at the policy level, at the systems level?

And then you go even further, underneath the surface, and you look at the mindsets, the mental mindsets. What do people think about who has accidents, as an example, and does the government or public health, have the authority to tell people they have to wear helmets if they ride motorcycles or they have to wear seatbelts if they’re driving cars, or they have to have the properly installed child safety seats if they have children of a certain age and weight. 

And some people’s mindsets are, “Yes, of course, this is something that the government needs to be accountable for, and to make sure people are safe.” Other people may say, “No, this is an individual choice. If I want to ride my motorcycle without my helmet and end up in the emergency department with a brain injury, that’s my choice.” So, you find that at the – below the surface, way below the surface is how people understand what happens to them. 

And to their neighbors, and people in their communities and in the world, and what they believe the appropriate solution should be, based on whether they think somebody is individually accountable or as you said, people are part of a broader community or our systems may be advantaged certain people and disadvantage other people. So, getting people to agree on solutions to these issues is really challenging because people have very different mindsets about why we have these issues in the first place. 

So, public health is not only about understanding the data and describing impacts to certain groups of people but it’s really navigating people’s mindsets, and bringing people together so that they can come up with solutions, where there is an understanding of all of the different causes and all of the potential ways to intervene, and hopefully, some agreement about what to do.

[0:12:04.8] JW: Yeah. You just unpacked a whole bunch of stuff, right? Like, there are so many directions that we can take this conversation but one of the things that stuck out in my mind is there are so many times and so many instances and so many situations where we are telling people, “Don’t drive off the cliff, you should know better, right? Don’t drive off the cliff, don’t do this, don’t do that.” While not understanding what are some of these other factors in play that can prevent people from driving off the cliff. 

Now, I’m saying, “Driving off the cliff” Metaphorically, right? That could mean, that could mean anything, right? Anything that may cause harm, right? And so, thinking about what are all the different factors — and the thing about it is everybody has a role to play. If our goal is to make the world better than we found it, then everybody has a role to play, and we need everybody included and involved and engaged, and like you mentioned earlier, that can create some tension, right? 

Everybody’s not going to agree on everything but we need to make sure that we have varying perspectives and that we are honoring and respecting what different people are feeling and thinking because we got to navigate around those mindsets, right? In order for us to be able to move together. So, one of the other things that I heard in what you were saying, and especially more talking about upstream versus downstream is so often, the data will lead us and tell us where we need to be going, right? 

But the thing about it is we’ve got to be clear and pay attention and understand that data alone doesn’t tell you anything but when you can look at data and interpret that data to tell a story, that can often lead us to what the solution should be. It’s a starting point, the data is a starting point, and we can figure out, if we work together, we can figure out how to utilize, how to best utilize that data to tell the story that needs to be told. 

So that we can make the decisions that need to be made, so that we can impact our communities in a positive way, and in a beneficial way, so that they can have a healthier outcome but that mindset piece is key, especially when you have leaders, right? Leaders and organizations, your nonprofit organizations, your community-based organizations, public health organizations. 

It’s really about solidifying what that mindset is going to be and understanding how do we move upstream. So, my question for you is, what challenges have you seen for folks who are in originations or leadership, when they’re trying to move, they want to move upstream, they’re trying to move upstream but we can’t quite get a handle on it. What challenges have you seen with it?

[0:15:09.1] DC: So, you are correct, it’s very challenging because public health has limited resources and we have everyday demands. You know, whether it be immunizing children or providing pre-conceptional healthcare to people of childbearing age, or dealing with communicable disease outbreaks, or sexually transmitted infections, there’s just so many, or environmental health concerns that come up, there’s so many like day to day challenges that public health under it purview is responsible for.

So, when you now say, “Okay public health, you need to move upstream, you need to understand what are the challenges that communities are facing around housing.” For example, or poor quality public education or food insecurity, or barriers to transportation particularly in rural communities can’t get access to a delivery hospital if you’re pregnant without going three or four hours away.

So, all of these things are, as you said, so critical to a person’s wellbeing and community’s wellbeing but how does public health garner the resources to actually work in those sectors? And the challenges that you need to work with others. It’s not just public health. Public health needs to convene, public health needs to be a chief strategist around how to work upstream but public health does not have the resources to address the housing shortage or the education system, or the transportation system, or food system. 

I mean, it’s just limited and so, the challenge is engaging people in a way that there’s a win-win. So, public health understands the win for communities, and bringing education to the table understands how this is going to be a win for education or housing. Like, how is this work, the shared vision, and the shared goals that we worked on together going to lift all bends? So, it will help with public health outcomes but is it going to help with education outcomes? 

Is it going to help with housing, is it going to help with transportation outcomes? So, people need to feel that there’s some benefit to their participation and they need to be organized, and we call this a collective impact approach, right? That there’s a way to work together, align your activities, communicate with each other so you’re not duplicating services or you’re not missing services that are needed, and that you’re going to have some kind of way to measure what it is you’re doing, so you can understand where you’re seeing improvements and where you need adjustments.

So, the challenge for public health is to step out of its day-to-day role of protecting and promoting the public’s health and be a leader in a community where you’re convening others to work on these really important issues upstream and most importantly, people who have the lived experience. So, it’s not just about governmental agencies and foundations and corporations or businesses coming up with solutions and then going to communities, and saying, “Okay, we have this figured out.” 

It is about identifying the assets in the communities that you’re trying to work with and then giving them meaningful input and opportunities for influence because they are living day to day in these communities and they know best what is most feasible and what is most likely to be sustained in those community. So, that’s challenging for government, right? To bring in people from lived experience and then to make them feel like they have a real meaningful role to play. 

So, I think those two things, the convening role and hearing the voices of people who are experiencing these challenges is really important. 

[0:19:06.6] JW: Yeah, and that’s what I find in my work with organizations as well as a community-engaged research consultant, that’s where we have to start. So many times, people will come to me with a challenge around, “Well, we want to do this research project.” And my first question is, “Well, how are you engaging your community?” And sometimes, they haven’t even started there. 

And not only do we want to engage the community but you already said this word, we want to have a meaningful, a meaningful engagement, build a meaningful partnership that really puts the community members or your community partners at the forefront because like you already said, they are – they have the lived experience. They are the experts. You come to the table as a leader organization because you’ve gotten your grant money, right? 

You’ve already figured out what the problem is and how you’re going to use this grant money and you haven’t even started engaging the community in the process and so, when we start shifting our mindset and start thinking about, “Well, how do we —.” We know we got to get upstream but the first thing in order to get in and I have these visuals though, I’m seeing all of us in a boat and I’m like, “All these organizations are going upstream without the community in the boat with us.” And something needs to happen. 

If you are in the boat and you are already downstream and your plan is to go upstream, you have got to put the community members and the community partners in the boat with you. They have to be with you as you travel upstream because it’s not going to make any sense that once you get upstream, you’re looking down the river, right? Saying, “Oh, now we got to help the folks downstream.” You should have brought them upstream with you. 

[0:20:51.4] DC: Right. That’s a great visual and it’s not something that we do very well in public health because we do think we have the data and we have the funding and we have all of the systems diagrams and the implementation approaches but we don’t have the buy-in, we don’t have the engagement, and then we go into communities and then oftentimes, where there, and then when the grant’s over and we’re gone and we haven’t built any capacity. 

So, I think that’s very true and you know we are seeing this more. I work a lot in maternal health, the important role of doulas and peer breastfeeding consultants, and people who can be trusted in the community because they’re from the community and they are able to connect better with community members. So, they really need to be an extension of our workforce and they need to be compensated appropriately for that work. 

[0:21:49.4] JW: Yeah, and the other thing that I’m thinking because now I’m in my visual, in my head now, and so the other thing that I’m thinking about is when you are downstream, right? And I’m thinking the river, right? You’re in a body of water, right? When you are downstream, when you are trying to travel upstream, you are traveling against some resistance, right? It’s not – it’s easier to go upstream than downstream than it is to go downstream to upstream. 

So, we have got to really be able to identify what is that resistance that we are going to be facing. We need to be able to come up with plans, right? Strategic plans on how we are going to push against this resistance in order to get ourselves upstream. Now, that resistance can look like a whole bunch of different things, right? That resistance could be systemic oppression, resistance could be policies that do not take all into consideration, all people into consideration. 

That could be racism, right? Cultural racism, systemic racism, any of that, right? So, we’ve got to be able to be in a place where as public health, as organizations, as those leaders that we are not only bringing the folks with us, right? Bringing the – engaging the community partners with us but also understanding that as you are traveling upstream, you’re going to have some resistance and knowing that ahead of time I feel like has been beneficial in my work with clients because I know the challenges are coming, right? 

They are there, we know where we got to go but we know some challenges are coming. So, a lot of that strategic approach in how we travel upstream is already thinking from the get-go, building it into the plan how are we going to handle these barriers. Now, you mentioned capacity earlier, right? And that’s another thing, another challenge that I hear from a lot of organizations, “You know, we don’t have the capacity.” 

We don’t have to deal with it but we don’t have the capacity to deal with this right now, right? So, what in your experience what are some of those key strategies or approaches that public health agencies or organizations can use to build their organizational capacity as they are moving upstream? 

[0:24:03.9] DC: Yeah, I think that’s really critical to support individuals and community organizations that are able to connect with people in those communities but may not organizationally have the resources or the skills and so, a lot of my work centers around building communities of practice or learning community, where people who are doing similar work are able to connect with each other, learn from each other. 

I use an approach called action learning, where you don’t necessarily get the solutions from your peers but they ask you questions to think about your challenges differently and people find that really helpful. I mean, everything is very contextually based so it’s not that something that’s working in community A on method work in community B but many of the challenges like you said, navigating distrust or building authentic partnerships or addressing historical trauma or oppression, many of those things are common across many communities. 

And I found that helping people connect with others who are doing similar work and learn from each other is one way of building capacity. Another way is helping them build the skills, whether it’s in writing grants or lobbying, or connecting with legislatures, or marketing and advocacy work. Some of those things that are foundational to successful organizations but may not necessarily you know, be in the organization. 

So, building that capacity based on starting where the organization is or the individual is and then identifying resources to support those organizations and communities but you really have to be in it for the long haul. I mean, this isn’t you know, a 12-month or 24-month engagement. I mean, transforming systems based on some of the research could take five to ten years. It could take a whole generation to really transform systems and communities. 

So, you have to make a commitment to walk in partnership with these organizations when you are trying to build capacity, just like you would anyone that you are mentoring or advising, a friend or colleague or peer that it’s a long-term relationship that you build over time and you provide resources and guidance and a lot of times, thought partnership, just to listen here rather than trying to just come and fix things and provide solutions. 

[0:26:40.8] JW: Yes, absolutely, and I love what you said about those learning communities, right? One of the foundational things that I work with my clients in building those community partnerships, those meaningful authentic community partnerships is that this is not a one-directional relationship, right? Relationships go two ways, so as a public health professional or if you’re a practitioner or researcher, yes, those community members may be learning from you. 

But you need to be open to learning from your community members and community partners because they have that lived experience. As we’ve already said, they are the experts and if we are going to have a truly collaborative environment so that we can address these challenges, address these issues, and start moving upstream, we’ve got to start taking time to learn from each other and part of that learning from each other is also building those skills, right? 

Not just building the skills of folks who are working in public health but also building the skills of our community members. Our community members should know how to create the survey, what that process looks like, right? What does it look like to submit an IRB application, right? Being transparent and open about how do we create these programs, how do we create these interventions, and they should be hands-on in that process. 

They are learning those skills right along with you and as you said, that is helping to build that capacity because now, you just don’t have your team of 10 staff members, right? At your organization who can do this work, you also have a team of 30, 40, 50 community members who can be engaged in this work as well, and be sure to pay them. I’m going to put that in there, I’m going to slide that in there for the agencies who haven’t been doing that. 

But make sure you’re paying your community members for their work and for their time but those are some things that need to be considered in how you engage with your community is building that relationship and understanding that it goes both ways. You can’t do one without the other if you truly want to move upstream because the more capacity you have, the more that engagement you have, the more authentic relationships, the more trust. 

You can start moving and pushing against that resistance together like that makes sense so, but it’s so hard to get folks who are in government or in policy or you know, the other leaders and external forces that we got to deal with who may not be directly in public health and some of them in public health too, but it’s so hard to get it across and get them to understand that if we can work together, we can work towards a common goal, if we can learn from one another, you know, it will be a lot easier for us to move upstream. 

[0:29:25.2] DC: Yes, I’m really glad that you highlighted that mutual learning piece because that is so key, particularly for people who work in governmental agencies. One example I’ll give is typically when you get grants, you don’t get the money until you demonstrate that you’ve spent the money. So, you need to have some money upfront to sustain you until you get reimbursed for your expenses. 

So, that can take 30 days, 60 days, 90 d6ays. I work at a university that’s a big administrative complex organization and people may wait a while to be paid. So, understanding as a government agency, if you’re giving funding to community groups, can you give them the money upfront and then have them document how they spent it over the period of grants but they don’t have to have the funding available to even start the program.

Things like that that the closer you work with community members, the more you understand some of their challenges and limitations, and they can’t function necessarily as a government agency might, and so adapting our approaches to enable them to do the good work that they want to do is really important. Some of the administrative requirements are really beyond what a small 501(c)(3) organization is able to do. 

So, building the capacity either for them to do that or to adjust our requirements that they can get resources because, in the end, it’s all about sharing resources and power, right? I mean, it’s all about stepping aside and listening and not stepping forward and acting like you know what to do but stepping aside and really working in partnership, which means sharing the decision-making, providing the data to the communities so that they have the same information you have, and then ensuring that they’re sufficiently resourced to do the work. Those are all really important things that we need to practice in our field. 

[0:31:23.0] JW: Yes, absolutely, and the bigger part of that is that all of those things are going to help us make positive change, right? And all of those things are going to help us to work together to not just do public health and you know, do the things that we love to do but also to bring our communities a source of joy in their lives as well, joy throughout the process, joy in having these solutions, right? 

Because that’s the part that we want to actually get to is the solutions once we move upstream. So, with that said as we wrap up, I do have one last question for you, and that question is what brings you joy in work? 

[0:32:04.8] DC: That’s a great question. I have absolutely loved my career in public health. I’ve been doing it a long time, and every day, it still invigorates me. I think what brings me joy is really the people who I’m able to work with. I remember when we first understood COVID and we were having to quarantine and stay at home, how isolating that was for me and I’m sure, for many people. 

Even though we had the technical means to connect to people, just that distance from people and not being able to work collaboratively in the team setting that I became used to was really hard to make that adjustment and so, I think people who work in public health or healthcare are a special group of people, and I feel privileged that I have the opportunity to work with such great talented, smart people who are really trying to improve their communities and their states and our country and the world, and so that brings me joy, and that keeps me positive. 

There’s lots going on that we can be less optimistic and sad about, especially over the last 10 years or so but I think knowing that there’s still people who are getting up every day and working on these really hard issues, it’s what keeps me going. So, I feel lucky that I’ve picked this area of work. I think it’s particularly when you’re looking at children and people of reproductive age and maternal health. 

I mean, what could be more gratifying than to try to ensure that the people we’re bringing into the world are the next generation of people are coming into the world loved and healthy and able to live their best lives? I mean, I think that’s the most important work we can do and so, I’m happy that I’m part of that.

[0:34:06.5] JW: Yes, and I think you’re absolutely right about that. If people want to get in touch with you, if they want to learn more about you and what you do, your organization, how do they get in touch?

[0:34:17.4] DC: So, they can email me at dcilenti48@gmail.com or they can go to my website at Health Ascent Associates and/or at my UNC address. So, you could just Google me and you will be able to find me at UNC as well in Chapel.

[0:34:37.1] JW: Okay, well, thank you so much for joining me for this conversation. This has been a wonderful time and Dorothy, we’re going to see each other later because we have a whole bunch of work to do.

[0:34:46.6] DC: We do.

[0:34:49.1] JW: So, this is going to wrap up another episode of The Public Health Joy Podcast. 

[END OF INTERVIEW]

[0:34:56.3] JW: I am so grateful for this time we get to spend together. If you enjoyed this episode, I need you to subscribe, rate, and leave a review. For more information on transforming public health research into positive community impact, visit www.joyeewashington.com. This is where research meets relationship and I’ll see you next time on The Public Health Joy Podcast. 

[END OF INTERVIEW]

 

[END]

 © 2024 Joyee Washington Consulting, LLC. All Rights Reserved.