An Intro to Grant Writing at CCHC

Charlotte Community Health Clinic (CCHC) relies on a significant amount of grant funding from diverse organizations. These include local faith groups, national non-profits, and the state and federal government. During my year at the clinic, I was given the chance to work on a number of these grants. Here’s three things I’ve learned as a result of my foray into grant writing:

Know your audience: It’s important to think about exactly who the funder is, in terms of what you write and how you write it. When I wrote a request to a local church, there was more flexibility to talk about individuals and their stories, express our organization’s belief in the right to access care and the inherent worth of individuals we care for. While that’s all well and good, when writing a grant request to the NC Office of Rural Health, they tend to care more about things like, well, money. In that grant request, we were careful to emphasize ROI, calculating potential community savings brought about by prevention of unnecessary ER trips. Different outcomes constitute impactful results for different audiences.

It’s a team effort: For some of the more formal grants I worked on this year, as many as five or six people would be involved in their writing. Typically, I would get to take a first stab at the narrative and work to find any clinical, local, or national data we might need to support our request. Requests for general operating funds were pretty straightforward because I could use fairly similar wording across grants. However, when writing for a new program, like when we wanted one of our providers to work onsite at a public housing location, I needed information from clinical staff to understand what the program would actually look like. Often times, the individuals that would know this (namely, our Chief Operating Office), would be busy with other things, like you know, keeping the clinic running, so I would take a stab at outlining the program. Then, when I had a chance to sit down with the COO she’d provide input as to what resources would be needed for the program to succeed and what I missed in the narrative. She would also help come up with reasonable objectives, usually with support from our data analyst. This would then get passed on to my supervisor, the Director of Development, who would work on the detailed budget and make my narrative sound a lot nicer (despite my Writing 101 professor’s best efforts, I’m the queen of unnecessary commas). When she was done, it would go back to the COO and CEO for final approval.

Outcomes are really, really tricky: Outcomes are what support the worth of your work. They give the grantor an idea of the tangible results that we anticipate coming if they fork over the money. However, there are a lot of things that make coming up with these objectives tough. Sure, we know that having a nurse who coordinates the care of our patients with chronic disease improves outcomes for them, but how do we measure that? 150 unnecessary ER trips avoided? Lower A1c levels for our diabetics by 1? A 25% increase in access to a patient care team? Are these objectives too broad, do they have too little direct correlation to the nurse coordinator, or are they too hard to measure? Even if we already track this data, do we have the capability to export it from our Electronic Health Records system? Additionally, what we think are significant goals may not seem that impactful to funders. For example, when we say the hire of a nurse coordinator will improve outcomes for our diabetics by 5%, we’re taking into account the many social determinants that impact our patients and the comorbidities that they often present with. But for some funders who may not understand our patient population as well, a 5% improvement may hardly seem a worthy investment.

It has certainly been a challenge to attempt to convey the value of our work to those who will never have the chance to meet our patients, but one I have very much enjoyed. It’s also been pretty great to start seeing the results of our efforts. Over the last two weeks we have received notice of having been awarded more than $170,000 for various grants we wrote earlier this year. While this may seem like a drop in the bucket, for us it means kick starting our effort to provide onsite services in public housing, buying medical supplies for our pediatric patients, providing health education workshops for seniors, and covering the cost of part of our nurse care coordination team. As I’m currently finishing out my final weeks here at the clinic, I won’t be around to see these funds in action. However, I’m grateful to have been given a chance to play a small part in tracking down the resources needed to let our clinic staff do more of their incredibly important work.

In the Pursuit of a Seamless Network of Care

Since the implementation of the Affordable Care Act (ACA), the number of insured people in the United States has increased; however, 12.2% (Q4 2017) remain without insurance in many communities. Healthcare safety nets continue to provide essential, community-based services to the remaining underinsured and uninsured people. Some of these individuals lack employee-sponsored coverage and their income is too high for Medicaid, some might be recent immigrants or seasonal workers, some might hold multiple jobs and still cannot afford marketplace coverage, and some might just have too low of a health status, are unemployed, and still are not Medicaid-eligible. Just navigating the complex system of government and local agencies takes a toll in the health of individuals and their families. The greatest issues still remain: access to care, affordability of care, and delivery of care.

According to the Small Area Health Insurance Estimates (2015), there are approximately 23, 317 uninsured adults between ages 18 – 64 in Cabarrus County, of which 42.1 % are below or at 135% of the Federal Poverty Level. More than one in seven (15.7%) adults report being unable to see a doctor in the past year due to cost (County Health Rankings, RWJF, 2015). I have been a Fellow at the Community Free Clinic since June of last year. To give you some context, we serve chronic working-age adult patients at 125% or below the Federal Poverty Level, with an annual re-certification process. As a central hub for HealthNet Cabarrus and the Pink Card Program, we provide access to on-site primary care, laboratory, behavioral, and pharmaceutical services, as well as specialty, diagnostics, and medical referrals. We have been serving the unmeet health needs of the county and its uninsured residents since our foundation in 1994. Currently, the Clinic has full time and part time staff, hundreds of volunteers including physicians, nurses, pharmacists, lab technicians, and many more. Our funding has come from several sources over our years of service: United Way of Central Carolinas, The Cannon Foundation, The Kate B. Reynolds Trust, Office of Rural Health Community Health Grants, The Leon Levine Foundation, Atrium Health/Carolinas HealthCare System – NorthEast, and private donations.

I have been involved in a series of meetings in order to develop a pathway for community members to more easily navigate our local system of care. The HealthNet task force has met for 18 working sessions, logging over 720-person hours to date to create a seamless system that serves the uninsured within Cabarrus County. Various health care and community organizations are involved in this endeavor: the Community Free Clinic, the Rowan Cabarrus Community Health Centers, Community Care of Southern Piedmont, Atrium Health/Carolinas HealthCare System – NorthEast, Carolinas HealthCare System – NorthEast Physicians Network, Cabarrus Health Alliance, Daymark Recovery Services, Cooperative Christian Ministry, and Cabarrus County Department of Human Services. All of us have the same goal in mind: to strengthen and revitalize the current health safety net for the uninsured population.

In a partnership with a team of consultants from Care Share Health Alliance, an organization that provides strategic support to other organizations forming coalition and safety nets in counties of North and South Carolina, we have strengthened our referral and enrollment system by implementing a web-based software, FHASES, to include multiple referral points and common data elements across partner agencies. Our principal goal is to increase the patient population accessing our services by 1000 within the next 12 months. With that in mind, we also want to increase individual trackability of referrals and appointments to make sure they do not get lost in the “black hole”. The collaborative has also focused in tracking population and individual data on social determinants of health. However, we will not only assess for SDOH, but also make the necessary referrals to local partners ranging from temporary housing to food pantries. This will be done using the Community Resource Hub, a platform established by Atrium Health using Aunt Bertha, that provides referral specialists the ability to close the loop.

Perhaps one of the most impactful experience has been working with these local, community leaders in the efforts to strategize and continue to meet the unmet needs of the Cabarrus community. The health care environment has shifted in the last 10 years with funding and policy becoming unstable and highly politicized. It has been fantastic to see the synergy among these organizations and leaders that continue to provide the necessary services to the community, and it has been a privilege being able to support them in this effort.

Learning from Change

My first two months at Habitat for Humanity International were a whirlwind. Friday of my first week I was asked to travel to South Africa to support final preparations for a regional conference we were organizing on land rights and governance. Saturday morning, less than 24-hours later, I was sitting on a plane watching DC shrink out of view. Coming back, my team jumped straight into pursuing new funding opportunities with tight deadlines. The hours were long and the learning curve was steep, but I learned so much.

Then, six weeks into my fellowship, my supervisor called me into her office and told me she had accepted a new option with Habitat and would be relocating to the area office in Pretoria, South Africa. I was excited for her, and also nervous for what the change would mean for my fellowship year. I did not know who would be my new supervisor or what my work assignments would be during the transition. While the main Habitat office is in Atlanta, my supervisor and I are based in DC, which is the government relations and advocacy office. The rest of our Global Program Design and Implementation team is based in Atlanta or works remotely. My supervisor and I worked extremely closely, being the only two D&I staff in DC. Every week my tasks changed to respond to new program and grant deadlines.

It would be impossible for me to separate my fellowship experience from the experience of supporting and navigating my supervisors’ transitions. So many of the professional and “soft” skills I gained this year came from this process. Here are five things I have learned and gained in navigating a supervisor transition this year:

  1. Patience and flexibility

There were a number of unknowns in the transition, in large part because the visa and relocation process is complicated, even for employees staying with the same organization. The timeline for opening a call for applicants to fill my supervisor’s positon was partly dependent on the timeline of her relocation, which was, in turn, dependent on her receiving her work visa. My supervisor was often out of the office, traveling to prepare for the new position or working remotely to facilitate collecting and compiling the lengthy documents for her visa application. Patience and flexibility in the face of uncertainty have been two of my biggest areas of growth this year, and I know these skills will be invaluable moving forward.

  1. New projects and opportunities

Because my supervisor had additional commitments and responsibilities, she asked me to take on new and different responsibilities. In November, I helped plan a learning exchange in Manila, Philippines, titled “Strengthening Land Tenure Security for Urban Poverty Reduction in Asia-Pacific.” Usually my supervisor would have traveled to attend and help facilitate the event, but because of the transition I had the opportunity to go and to represent the Global Programs Design & Implementation team. Now being the only staff member on my team based in DC, I have also had a number of opportunities to represent Habitat for Humanity at various sector events, including working groups, and workshops hosted by USAID and the US State Department.

  1. Connecting and collaborating with new colleagues

As I previously mentioned, Habitat’s DC office is the organizations’ Government Relations and Advocacy office. With my supervisor in transition, I have been able to be more involved in supporting collaboration between our team and the global advocacy team. Through this collaboration have learned a lot about access to land and tenure security, which is the focus of Habitat’s global advocacy campaign, Solid Ground. With the global advocacy team, I helped coordinate Habitat’s 30-person delegation at the ninth World Urban Forum (WUF9) in Kuala Lumpur, Malaysia where we were engaged in more than forty events and presentations. WUF9 is the premier global conference on urban issues and development. It was incredible to spend a week in Malaysia learning about, and working towards, more sustainable and resilient cities with 22,000 attendees from 164 countries.

  1. Two-times the expertise to learn from

Having two different supervisors this year has also meant that I get to learn from two highly qualified experts with different professional background. My first supervisor was an expert in urban planning and development, with experience working for UN-Habitat, the World Bank and the Inter-American Development Bank. She was instrumental in developing Habitat’s extremely successful REELIH project and building a coordination structure for our Water, Sanitation and Hygiene (WASH) programs. My new supervisor is an expert in WASH and disaster response, with over 20 years’ experience in the development sector. He has responded on the ground to the Haiti earthquake in 2010, Japan Tsunami in 2011, Typhoon Haiyan in 2013, Nepal earthquake in 2015, and the refugee crisis in South Sudan. I am so fortunate to have worked closely and built relationships with both my supervisors, who are generous and take the time to explain new concepts, tools and methodologies to me.

  1. Looking forward and back

I was eight-months into my fellowship when my new supervisor started in his position, and I was grateful to be able to support his transition by compiling and sharing resources, providing background, and sharing my experience working on Habitat’s land, urban, WASH and gender programs. In a role that has often been very face-paced, his transition has helped prompt me to reflect back on my experiences this year. I am reminded of just how much I have learned this year. Helping explain Habitat’s unique structure and programs now will also prepare me to on-board the next Davidson Impact Fellow this summer.

Change, it is said, is the only constant in life. Its inevitability does not, however, make it easier in the moment (at least not at first). In can be hard to see opportunities when you are in the midst of uncertainty — I know because, nine months ago, when I was told this would be an important learning opportunity I struggled to see past the challenges that come with change. Now, I am infinitely grateful to both my supervisors and the experiences I have gained, which I know will serve me well beyond this role as well.

More Than a Roof and Four Walls

As a young professional in DC, one of the first questions I usually get asked is, “Where do you work?” I’m lucky because almost everyone has heard of Habitat for Humanity. But most people I talk to have no idea that Habitat for Humanity is a global organization, operating in nearly 70 countries.

In the US, Habitat is best known for mobilizing large teams of volunteers to build homes for low-income families. Families contribute sweat equity during the construction process and commit to repaying the cost of their home through a no-interest mortgage. It is incredible what can be accomplished with many hands. Last summer, over the course of a week, volunteers built and renovated 150 homes for the Carter Work Project in Edmonton, Canada. Habitat volunteers are so efficient they make housing look easy! But in reality, housing issues are incredibly complex, bringing together a wide range of sectors and systems.

As a Davidson Impact Fellow, I support Habitat’s global programs in a number of areas, including WASH (water, sanitation and hygiene), energy efficiency, urban development, gender equity, and land tenure security. Housing is more than a roof and four walls. In order to realize Habitat for Humanity’s vision of a world where everyone has a decent place to live, we must address all aspects of housing that affect low-income families around the world.

Adequate housing was recognized as part of the right to an adequate standard of living in the 1948 Universal Declaration of Human Rights and in the 1966 International Covenant on Economic, Social and Cultural Rights. According to these standards, for a particular form of shelter to be considered “adequate” it must meet a number of conditions, including security of tenure, availability of services and infrastructure (water, sanitation, energy for cooking, heating, lighting, etc), affordability, habitability, accessibly, location, and cultural adequacy. In many regions around the world the greatest housing challenge is the quality, not the quantity, of available housing units. Addressing the global housing deficit often requires creative incremental solutions, rather than building new housing units. I want to introduce you to two of Habitat’s international housing initiatives to give you a sense of both my role and Habitat’s role as a leader in the global housing sector.

Solid Ground – Access to land for Shelter
The biggest surprise of my fellowship came right at the beginning: on Friday of my first week I was asked to go to South Africa to help finalize preparation for a regional conference on land governance and tenure security. I left the next morning! I will admit, on my way to South Africa I was not 100 percent sure why Habitat for Humanity – a housing organization – would be organizing a conference on land. But the answer is clear: without land there can be no housing. Access to land and housing fosters strength, resilience, and lies at the heart of ending poverty. At the regional conference, I learned that only about only about 40 countries in the world have well-functioning land administration systems, and in most developing countries less than 10% of the land is formally registered. Globally, 75 percent of people lack proper documentation to the land on which they live. Housing currently accounts for more than 70 percent of land use in most cities, yet 1 billion people living in cities lack secure land rights. Without secure tenure, families live in fear of eviction, loss of livelihood, and are often unable to access basic services, including water, sanitation and electricity. In 2016, Habitat for Humanity launched Solid Ground, the organization’s global advocacy campaign that aims to increase access to land for shelter for 10 million people. Local Habitat for Humanity organizations and partners implementing the campaign in 37 countries, and have already improved policies and systems projected to increase access to land for shelter for 1.6 million people. Without the constant threat of eviction looming, families feel secure to invest in their homes, making incremental improvements that increase both their quality of life and disaster resilience. Helping convene an international conference on land with 98 participants from over 20 countries really reinforced for me the intersectional nature of housing issues. Visit the Solid Ground website to read more about the conference my experience.

REELIH – Energy efficiency retrofits and market systems
One of the most unique Habitat programs I have had the opportunity to support is REELIH – Residential Energy Efficiency for Low Income Households – a joint project with USAID, which aims to improve living standards in multi-unit apartment buildings in Eastern Europe by developing regional and national strategies and resources to address the impact of rising energy prices on collective housing. Basic services – including energy, water and sanitation – are vital to adequate housing. Over 50% of Armenians, and 20% of Bosnians live in multi-unit Soviet-era residential buildings. These buildings, which account for 75-80% of apartments in Armenia and Bosnia and Herzegovina, were constructed cheaply, and often without any insulation. Traditionally energy costs have been heavily subsidized by the state, but now, with energy costs rising, a considerable portion of the region’s population lives in energy poverty – defined as spending more than 10% of household income on energy in order to heat their homes to a minimum standard of warmth. In winter months, families in Armenia and Bosnia and Herzegovina can be forced to spend 30-40% of their disposable incomes on heating. To date, REELIH has completed pilot retrofits on over 1200 housing units in three countries, providing families up to 50% in energy savings. Results from these pilot projects fuel advocacy activities to influence public policy and the energy efficiency sector. I’m not the only one who thinks REELIH is an amazing and innovative program – it recently received a special mention for the World Habitat Awards, which “recognize and highlight innovative, outstanding and sometimes revolutionary housing ideas, projects and programmers from across the world.”

These are just two examples, but Habitat for Humanity International has programs that address all aspects of “adequate housing”. The programs, and the houses themselves, may look different in each of the 70+ countries where Habitat works, but they all align with Habitat’s commitment to building strength, stability and self-reliance through shelter.

 

From Directionless to DIF and On…

 

As I approach the last quarter of my time as a Fellow and head on to pursue my Masters of Public Health next fall, the DIF’s fearless leader in Career Development asked if I might share how I got here from last year when I had no inkling of what I might do the next year, let alone for the rest of my life. So here goes…

During undergrad, it seemed like most of my friends figured out what they loved early on, from chem research to music theory, and stuck with it. Meanwhile, I had a blast bouncing around from gene editing and behavioral ecology to as many East Asian religions classes as I could sneak in (take a class with Dr. Pang and thank me later). But even after hours lounging outside the Union listening to tour guides assure parents that Davidson produced students before athletes (“Athletes and other students all go to the same classes AND eat in the same dining hall!”), I can’t deny swimming was my thing. I enjoyed going to class, but heading to Baker to try and chase down the guys at the end of a long set? That was what I loved.

Then senior year rolled around, and I was still sitting outside the Union drinking gallons of Honest Tea, now mulling over the fact that “run of the mill athlete in low interest sport” didn’t have a great post-collegiate outlook. I decided to buy more time by applying to a bunch of one year positions to put off figuring out what I actually wanted to do. I got an interview for the DIF’s Community Health Cohort despite having no significant public health background nor having taken a single public health centered class. The interview fell while I was off at NCAAs that spring, so I watched some quick webinars on the US health care system in between sessions, Skyped in from my hotel, and hoped for the best. Three months later, I walked in to my first day of work at Charlotte Community Health Clinic (CCHC).

Fortunately, my colleagues cared less about what I knew how to do and more about what I could learn to do quickly. I started by researching and writing grants, getting trained in EPIC (our electronic medical records system), and learning about the data gathering and analysis required for our federal grants. I taught myself our donor management system and became responsible for it. I worked with our referral coordinator on our follow-up process, rewrote our volunteer program, and worked with the community at outreach events. I interviewed our patients for advocacy and development purposes, analyzed our clinical and demographic data, and worked on program planning for expanding our women’s clinic and HIV services. I had the opportunity to sit in on a variety of health related community coalitions and work with my own cohort on writing a grant proposal for a resource we identified as missing from all of our clinics. And, I find value in the work I do. When I get tired of sitting at my desk for ten hours, I think of one of the countless stories that trickle back from clinical staff of lives changed and of individuals able to do the things they love most because of CCHC’s work. It’s more than enough to keep me going.

So, if you don’t know what you want to do next year, find an opportunity like this one that lets you try a little bit of everything. The exposure to a wide range of experiences allowed me to quickly identify what was not my thing (development) and what might be (health intervention implementation). By the time late fall rolled around, I had realized community focused public health was something I could imagine myself doing for the rest of my career. I look forward to getting to play with data while trying to communicate it in a way that creates the potential for systems level change. I’m excited to still work with the strict quantitative perspectives I revered in bio classes interwoven with the unpredictable challenges that surface when you try to apply them in real communities. I love how public health pulls from the multitude of disciplines and experiences I enjoyed at Davidson but never quite figured out how to tie together.

So, should I have tried to narrow my academic focus more while at Davidson? Probably. If I had to redo it, would I do anything different? Probably not. I had the time of my life making swimming my thing at Davidson. And, despite not finding my exact academic passion while at school, I’m still confident that I gained the writing, communication, and critical thinking skills that will allow me to tackle the challenges of a career in health interventions. I’ve now lived one of the benefits of a liberal arts education: my time at Davidson prepared me for a career I didn’t even know I was interested in while at school. So to any panicking seniors that don’t know where you’ll end up, go get yourself a Union Egg & Cheese Wrap (potentially what I miss most about Davidson), relax, and maybe apply for a DIF Fellowship or two. When you eventually figure out where you want to be, chances are Davidson has already given you many of the skills you’ll need to succeed there.

“The Magic of the Schloss”

When I told my peers at Davidson that I was going to be working for Salzburg Global Seminar with my Davidson Impact Fellowship, a common response was, “Oh, that’s the one that goes to Austria, isn’t it?”

Though I do a whole lot more in the DC office, I did have the chance to visit Salzburg, where the Salzburg Global magic happens.

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For about two weeks in October, I had the opportunity to work from the main office of Salzburg Global Seminar in Salzburg, Austria. And “office” is incredibly misleading – the organization is based in Schloss Leopoldskron, an 18th-century Archbishop-Prince’s family-residence-turned-home-of-Max-Reinhardt-turned-hotel. And, no, I never got used to the fact that we staff ate lunch in a room off the kitchen that would have suited 1740s church-state royalty.

I wasn’t sent to Salzburg just to admire the architecture, though. In DC, I’m on the development team, working to fundraise from individuals and institutions for what happens in Salzburg.

So what does happen at Salzburg? Quick history lesson: Salzburg Global Seminar was founded in 1947 (we’re celebrating 70 this year!) by three young men from Harvard who envisioned a “Marshall Plan for the mind” to help Europe recover from WWII. For six weeks during the summer, men and women from all over Europe – people who had been enemies just months before – gathered at Schloss Leopoldskron for a session on American Studies. The topic was chosen for its relative neutrality, but over the course of the session, participants – some of whom had been members of the Nazi Party and others who had been active in resistance movements across Europe – became comfortable enough to discuss their own countries and issues.

Today, Salzburg Global Seminar is a nonprofit that includes many other sessions in addition to American Studies, ranging from healthcare to environmental care, genocide prevention to corporate governance. Both current and rising leaders from all over the world come together for about a week at the Schloss for each session to exchange different perspectives on global problems, and come up with solutions.

All this I had read and written about many times in DC, but I’ll admit I didn’t have a complete grasp on what Salzburg Global really did. Until I got to Salzburg, that is.

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The thing that struck me was the “magic of the Schloss.” I had seen that phrase back in DC, and was admittedly a bit skeptical. But as it turns out, there is a magic to this place. From the stunningly beautiful library (with a secret staircase!) to the rococo-style rooms to the grounds with the stone seahorses, Leo and Mo (who make an appearance in the lake scenes in The Sound of Music), there was a definite tranquility all around.

The other part of the “magic of the Schloss” was the thought-provoking conversations that happened between the Fellows. I helped out with the sixth annual Young Cultural Innovators session, during which about 60 twenty-five to thirty-five-year-old artist-activists and social innovators from around the world convened at the Schloss. To say that these people were fascinating, inspiring, and just really cool would be an understatement. (There was also an unexpected Davidson reunion – one of the participants was Calley Anderson, ’14!)

In addition to the scheduled lectures, workshops, and panels, these Fellows organized their own discussions to get further into the issues – including a “Shop Talk” conversation based on barbershop culture – complete with uncomfortable questions and an actual haircut! I really believe there’s something about the atmosphere created by the sessions at Salzburg Global that allows people to ask hard, awkward, and prickly questions and discuss them in a totally open manner – not unlike some of the experiences I had in classrooms at Davidson. That’s the real magic of the Schloss, and the core of what Salzburg Global does.

One night, some of the Fellows organized a program – “The Schloss is Alive” – to exhibit some of their work that they had done in the past, and some they had collaborated on together in the past few days. I wish I could do it justice. The work they showed – documentaries related to their own First Nation community, photography as art and activism, an animated video to a jazz-traditional-Albanian song – and the passion that was obvious in their presentations was honestly moving. And seeing a Japanese musician, Nigerian rapper, South African poet, Canadian pianist, and Japanese dancer – people that had met just days before – perform a beautiful piece all together was something that embodies what can happen at Salzburg Global.

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Back in May, when I was explaining my new job and organization to various people, I occasionally got the very skeptical reply, “Okay… so they basically get people together to talk for a few days?”

Okay, basically, maybe. But this is truly transformative talking that happens, with connections and collaborations and projects that last well beyond the week at the Schloss. I’ll admit there are moments of frustration in writing fundraising appeals for an organization that doesn’t have tangible and easily-quantifiable results. But how many of us have had our perspective shifted from a conversation with someone totally different than us, but with similar interests and passions? How many of us have driven ourselves in circles with an impossible problem, only to have someone come in and flip the puzzle around, suddenly revealing a whole new set of possibilities? That’s what I saw happen at Salzburg Global.

So, given all that, I must have been super bummed to get back to the daily grind of DC, right?

Well, not so much. While I miss my co-workers across the Atlantic and the verified magic of the Schloss, I was really excited to get back to DC and contribute what I can to this organization, now that I’ve seen it in action.

Plus, there is something to be said for home sweet home… even if it’s not an Austrian palace.

The World is Melting! Do Trails Even Matter?

When I talk to people in the community about what the Carolina Thread Trail (CTT) does, their response is often something along the lines of “trails? I don’t do that.” But after talking for a few minutes, I almost always discover that they, in fact, walk their dog along a greenway that is part of the Thread Trail or take their kids to a riverside park we helped to fund with grant money as part of a project to establish blueways or paddling trails. These types of conversations have driven home for me the way in which we often interact with the built environment and use environmental resources unconsciously. This lack of attention to modes of habitual contact with the natural world can mean that many people don’t make the connection between their quality of life – their ability to spend time outside with their kids or grandkids or to walk safely to the store or a friend’s house – and the need to conserve the environment.

I have learned a lot in my first few months at the Thread Trail but one of the most important lessons has been the importance of identity in gaining community support for environmental conservation. The Thread Trail puts a name to the small trails and greenways across North and South Carolina – it allows the people who use those trails every day to connect to a larger regional identity. Establishing this connection with nature has been an integral part of the  mission of the Carolina Thread Trail since it was created out of the Catawba Lands Conservancy (CLC) in 2007. The Thread Trail still works closely with CLC and both organizations do important work in environmental protection. I think that the Thread Trail, however, is a uniquely important tool that provides something the Conservancy cannot. CLC protects large areas of land, providing critical wildlife habitat and sequestered areas of forest where native plants can flourish, but all that land, all the native flora and fauna, is not accessible to the public. CTT preserves smaller areas of land, often in unglamorous habitats on floodplains filled with scrubby bushes and briars, but every inch of that land is open to the public.

This type of community-focused environmental effort is what I believe will make the difference in rapidly developing areas like the Piedmont of the Carolinas. While monumental conservation projects like Yosemite or the Great Barrier Reef often serve as emblems of the environmental protection movement, they are not representative of daily modes of interaction with nature for most people. When I think back to the conception of my own interest in the environment, I remember weekend walks in local parks with my family and days spent exploring the scrubby woods in my neighborhood with friends. These outdoor spaces of my childhood are not glamorous by any means, they are the in-between spaces carved out around neighborhoods and stores and schools. Such spaces are not particularly significant individually, but if we can make it possible for every child to have access to open space in which to run and explore, however unspectacular that landscape is, we will likely have far more environmentalists in the coming decades to combat global climate change, biodiversity loss, and the plethora of other large-scale issues we face. The in-between spaces that sparked my interest in conservation are invisible to many but are transformed into places – into landscapes of wonder – to those who care to look closely and spend time in them regularly.

This transformation is what the Carolina Thread Trail facilitates. The Trail opens up these invisible spaces and invites people in – people, hopefully, like me, who will one day look up and realize that their little slice of nature, the small trail behind their house or their local park, is a piece of something so much bigger and so much more significant than just themselves.

Adding Voices to the Numbers: Stories as Advocacy at Charlotte Community Health Clinic

Last week, the clinic that I work for, Charlotte Community Health Clinic (CCHC), participated in National Health Center Week. During this week, across the nation, Federally Qualified Health Centers (FQHCs) put on free events like pediatric immunizations and health fairs for the community. Since FQHCs differ from free clinics in that they are more dependent on federal funding, this week is also used in part to let elected officials learn more about the work health centers do. As a part of this task, we spent some time interviewing and photographing patients and staff to learn more about their stories so we could try and share them with the elected officials who attended our events. The end result was small note cards with quotes pulled from the stories of patients and staff that we put on the tables at our big celebratory breakfast.

It was a strange to see the people we had interviewed, including some patients who had talked to us for hours, whittled down to a sentence or two taken out of context. It felt like I had done our patients an injustice in not having conveyed the complexity of their stories. In describing the community we serve, our patients tend to get thrown in big categories, like “low-income,” “homeless,” “unemployed,” or “immigrant.” Yet, the first thing many of the patients I interviewed tried to do was make clear that that they didn’t fit neatly into one of those molds. From the patients who had worked as teachers or engineers for thirty-some years before being laid off, to the Pakistani immigrant who had been a US citizen for decades and paid taxes since day one, many of these patients were aware of the stereotypes that tend to be associated with those seeking low cost healthcare. For some, fighting those assumptions was why they were willing to share their stories.

The stories themselves ranged from frustrating to heartbreaking. There was the woman who searched and searched for somewhere to have a mammogram but by the time she found us and got one through our clinic she was diagnosed with Type II breast cancer and went on to have a double mastectomy. Or there was the family whose grandmother simply could not get her diabetes under control, not because she wasn’t trying, but because she had to eat whatever her neighbors were kind enough to give her. Since one son had been killed, and the other deported, she couldn’t afford to be choosy as she struggled to take care of all her grandchildren. Others were more pragmatic, describing how primary care keeps people working and keeps people away from expensive ER trips. Some stories, like the woman whose daughter had a lump in her breast but couldn’t afford the further testing to determine if it was cancerous, were almost inconceivable.

As it turns out, it’s impossible to capture the injustice of not being able to afford to find our whether your daughter is going to live or die in a sentence or two on a notecard. At the same time, it’s hard not to wonder who might be compelled to action if you could. At our National Health Center Week events, both Mayor Jennifer Roberts and Congresswoman Alma Adams made clear that there is a clear need for increased health care access in Mecklenburg County, and Congresswoman Adams acknowledged, “A medical emergency does not care if you are a Republican or Democrat.”  While that’s a hard statement to argue with, many across the country still seem to disagree about whether the care for that emergency should be a right or a privilege. For my part, I wonder how many more people would support the right to basic health care access if they had the opportunity to meet the people whose complex stories and struggles are lost behind the numbers thrown around regarding our health care system.  One challenge I look forward to as I continue my year at CCHC is figuring out how I can better amplify those voices, as I have no doubt that these are stories that deserve, and need, to be heard.

Understanding trauma and resilience through research, real stories and reality… my reality

I’m sure you are all well aware that social factors affect health. This framework was not unfamiliar to me when I first started working at Mountain Area Health Education Center (MAHEC). I understood that social experiences can influence health, but I didn’t realize to what extent until I began a research project at MAHEC on childhood trauma.

You might be wondering how traumatic experiences from childhood are related to clinical medicine? Trauma lives in not only the mind, but also the body. There is a rapidly growing body of evidence to support this. In 1998, Drs. Anda and Feletti published a study, which found a significant correlation between health outcomes and childhood traumas (referred to as “ACEs” or adverse childhood experiences”). Adverse childhood experiences include physical, sexual or emotional abuse, physical or emotional neglect, and household dysfunction, such as losing a parent or immediate family member to death, witnessing domestic violence, or having a parent with mental illness or substance abuse. Even when controlling for variables like socioeconomic status, the researchers determined that a person who has more than three ACEs has an increased risk for liver disease, diabetes, chronic obstructive pulmonary disease, and heart disease among other medical conditions.

After reading the 1998 ACE study, I asked myself, how does this happen? How do childhood experiences from 30 years ago have such a lasting physical imprint on a person? My curiosity prompted me to dive into the medical literature. I yearned for a scientific explanation. Luckily for me, since the initial 1998 study, scientists have made tremendous progress in understanding the physiology and neurobiology of trauma. A lot of the research has explored the role of the fight-or-flight response, which, as many of you probably already know, is an adaptive system in our bodies to help us in threatening or dangerous situations. This response sends energy to your muscles when you need to suddenly slam on the breaks to avoid a car crash. It increases your heart rate and respiratory rate when you see a bear in the woods and need to run. But imagine if that bear was your physically abusive father… imagine if you felt a sense of danger every night when “the bear came home from work,” explains pediatrician Dr. Burke Harris in her Ted Talk on ACEs. When a child is repeatedly exposed to trauma, his or her system of alarm will be continuously activated. The expert psychiatrist Dr. van der Kolk states, “Long after the actual event has passed, the body may keep sending out signals to escape a threat that no longer exists”. These excess hormones, like cortisol and adrenaline, can cause toxic stress and have a lasting impact on the brain and the body. ACEs are both a social issue and a medical concern.

Learning about ACEs flipped a light switch inside of me. I reconsidered my approach to medicine and  began to think about addressing the underlying cause of disease, which involves addressing trauma in many instances, instead of only treating the symptoms. I started seeing connections between childhood trauma and many other public health issues. During my time at MAHEC, I have witnessed the devastating impact of the opioid crisis on individuals, families and communities in western North Carolina. After I learned that opioids and other substances act on receptors in the brain and essentially numb the neurobiological effects of trauma, I began to examine our opioid epidemic with a different lens. What if we also have an ACEs epidemic?

My research on ACEs greatly influenced the way I approached my clinical work at MAHEC. I began to comprehend why people engage in certain behaviors. My mentality shifted from “what’s wrong with you?” to “what’s happened to you?” I began to ask patients more questions. I made a deliberate effort to learn about their backgrounds, to listen to their stories in order to understand. Hearing patients’ personal narratives transformed my abstract understanding of trauma into a tangible reality. ACEs were not a phenomenon in an academic journal anymore; they were real, raw human experiences.

After listening to some truly astounding stories, I felt overwhelmed and helpless. What can I do to address trauma? There isn’t a miracle medication to erase the past. Although there is no magic pill, I learned that experts have developed many specific strategies that can boost patients’ resilience and reduce the effects of trauma. There is currently a movement in public health to teach doctors and other allied health professionals about how to promote resilience strategies and provide “trauma-informed” medical care. Through MAHEC, I learned about an innovative approach called the Community Resiliency Model, which aims to educate not only the patient, but also the surrounding community about the effects of trauma and empower them with the techniques and skills to boost resilience. Some of these resilience techniques can literally reset the nervous system, mitigating the physiological effects of trauma. The Community Resiliency Model is based on the notion that “it takes a village” not only to raise a child, but also to heal one. Helping an individual recover from trauma requires bringing together community members to create a trauma-informed, resiliency-focused support network.

Several months into my fellowship, I gained a new perspective—a highly personal one— on trauma after my own adverse experience. During the fall of 2016, my older brother passed away very suddenly and unexpectedly. When I received the phone call, my fight-or-flight response was activated before my brain could begin to process what had actually happened. Trauma lives in not only the mind, but also the body. As I heard the words “he’s gone” uttered, I felt my heart rate rapidly accelerate. I began to hyperventilate inside the Asheville Target. It was the strangest thing because I had learned all about the physiology of trauma from my research on ACEs. I knew exactly what was happening to my body, but I couldn’t do anything about it.

The weeks that followed my brother’s death are still a blur to me. But one thing I distinctly remember is having a loss of words. When I tried to speak, nothing came out. There weren’t words that could fully capture the horror of what I endured. I thought back to something I learned from my research: when experts used neuroimaging techniques to analyze traumatized brains, they saw that Broca’s area, the part of the brain that controls speech production, was shut off. This happened to me. My brain physically could not produce words (on a side note, I have found writing this blog post to be an empowering way to reclaim my words).

I was a living example of everything I had learned about through work. As a result, I was better able to grasp patients’ experiences of trauma. I felt a deeper sense of empathy for them. I had an urge to tell all of my patients, “Your pain is valid. I recognize and understand your suffering and I’m so deeply sorry for your trauma.”

When I returned back to my life in Asheville, I struggled… a lot. I could barely concentrate on simple tasks at work. It felt like my brain was surrounded by a fog of trauma. My grief felt like a heavy backpack full of bricks, an unbearable weight that I carried around constantly. I would frequently break down crying during the middle of the day. Whenever it happened, I would say to myself: Get it together, Natalie. Control yourself. But I couldn’t always. Trauma and grief are incredibly powerful. I felt overwhelmed. Above all, I needed support from the people around me, but I felt guilty and embarrassed asking for help. I prided myself on doing things independently. I can make it through this on my own, I thought. I was also very accustomed to helping and taking care of others, so it was deeply uncomfortable for me to become the patient, to acknowledge that I needed to be healed and cared for. However, once I admitted this to myself, it made all the difference.

With the Community Resiliency Model in mind, I began reaching out to the people around me—to my community in Asheville. Once I asked for their support and help, my trauma became less overwhelming. There were more people to help me carry my heavy load of bricks. Why did I ever try and do this on my own? My community has been unbelievably supportive and kind. I will never forget the compassion I received during this time. I also started using the resilience techniques that I learned about on myself. Over time, it has become easier to breath. Although I am still profoundly sad about my loss, I feel more resilient and connected because of my supportive community. It took a village to help me on my path of healing.

My raw pain is now the underlying force that fuels my passion for medicine, health and healing. After learning about and living through my own trauma during my Davidson Impact Fellowship, I understand that both health and healing are complex processes. Given that social realities impact these processes, I recognize that my situation is one of privilege. It greatly disturbs me to think about the fact that there are so many people, especially young children and socially vulnerable individuals, who experience horrific traumas with less resources and support than I had. I am more determined than ever to combat this injustice and serve as a supportive resource to vulnerable patients; to be present with them on their journey towards healing.

Ultimately, this year has left me inspired to provide trauma-informed care to my patients and to educate my peers (why I chose to write about it in this blog post), colleagues, family and friends about ACEs and resilience. I hope that by spreading this message throughout my medical career, I can help my patients and my community become more resilient. It really takes a village—a resilient, supportive, connected village—not just a person with a stethoscope, to help people heal.

 

Dirty Jobs: Land Conservation and Environmental Management

My time at Catawba Lands Conservancy and Carolina Thread Trail has been split in many different directions, doing many different types of work, and working with all types of people. You can really learn a lot about the society we live in behind stands of pines and hardwoods, in the riparian lands along our creeks and rivers. Last week I went on a site visit to a Catawba Lands Conservancy (CLC) property (I won’t specify the exact location so all landowners may remain anonymous). This conserved land is separated by just a few parcels, and as many landowners from our most popular natural surface trail in the Carolina Thread Trail (CTT) network. To make this connection, would add about two miles onto our existing trail, and is a very tangible goal depending on landowner cooperation. That being said, I and two others went to the site to walk the corridor and assess trail possibilities. What we were met with was both exciting and discouraging.

Our walk started off through a managed forest of loblolly pines, which make for a great trail because of the relatively clean understory and forest floor, and then shifted down to the creek bank where the walking got a bit more laborious, but still had great potential for a trail. The creek wandered through the forest, large native pines and hardwoods on the east bank, and an intimidating wall of invasive privet on the west. Eventually the forest gave way to a wide, beautiful wetland area fed by a creek (name undisclosed) and the flood waters of the lake (name undisclosed). This area was quite pleasant this time of year, but would be a breeding ground for mosquitoes in warmer weather. The wetland area would require a series of bridges or boardwalks to implement a sustainable trail (although bridges and boardwalks would be a nice amenity for users, it can be a very expensive obstacle for us). Back into the woods we went for a short distance until we reached an untouched pool of the lake. This water body encompassed about ten acres, but was only about two feet deep and littered with trees, fallen branches, and exposed islands of grasses—a heaven on earth for wood ducks and other waterfowl. As we approached, sure enough, we bumped up a pair of wood ducks, a blue heron, and three Canadian geese. This was a beautiful sight, and rare to see on a commercialized lake such as this one. Our admiration, unfortunately, soon turned to dismay as we made our way around the water and saw the disgusting scene on the other side.Dirty Jobs: Land Conservation and Environmental Management

As we circumvented the pond, we came upon a litter pile of glass and plastic bottles, plastic toys, beer cans, tires, Styrofoam, and old household appliances. This was the largest and most dense litter pile I have ever seen in an undeveloped area. It was amazing amount of trash, and we soon came to realize that to make a trail a reality in this area we would need to have multiple volunteer workdays with many hands working diligently for hours, filling several dump truck loads of trash for removal. Trash pickup is not the most glamorous work in land management, but one that is necessary in many cases. This is one of the “dirty jobs” in land conservation work, and frankly, a job that can be over-looked or brushed under the rug because of the limited resources in small land trusts and other environmental organizations like ourselves.

As a conservationist, this is extremely frustrating to see. Trash is a serious problem in our society and a major concern for the environment through its impacts on wildlife, water quality, etc. Action needs to be taken on this front, and I’m not exactly sure what that will look like. Is it local, state, or federal policy changes? Or is it an effort made through corporate responsibility initiatives from companies producing these products, maybe an effort at the grassroots level? I’m not sure, but if something isn’t done about this soon, the increasing global population combined with the societal obsession with Dirty Jobs: Land Conservation and Environmental Managementon-the-go products, fast food, and plastic products will be the demise of our natural environment as we know it today.

Seeing is believing. It is hard to wrap the human brain around something of this magnitude from anecdotes and photos, so it is important for organizations like us to get people outside and facilitate this conversation. But remember, non-profit environmental organizations love volunteers and would fall apart without them. So please look into spending some time researching and finding places to get involved in the conservation efforts wherever that may be.

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