HealthChangers Podcast: Healthy Food, Healthy Communities

June 18, 2019

Forty-five million people in the United States live with food insecurity. That is one in every eight households, making it a national epidemic.

This issue hits particularly close to home. Oregon has one of the highest childhood food insecurity rates in the nation. They live in homes where they lack available financial resources for food at the level of their household size. This impacts one of every five local children.

In this episode of HealthChangers, we are taking a closer look at what is being done to help address this public health crisis in our own communities. Today, we’re joined by Angela Dowling, the President of Regence BlueCross BlueShield of Oregon. She’s also on the board of the Oregon Food Bank. It is an organization that is addressing our communities’ need for nutritious food today, while also creating a long-term solution to hunger.

Angela recently sat down for a conversation with Susannah Morgan, CEO of the Oregon Food Bank.

Understanding How Systemic Inequities Cause Hunger

Rachel Day: Welcome to the HealthChangers podcast presented by Cambia Health Solutions, where we share real stories of health care transformation from those experiencing it, and those helping to make health care more personalized. I’m your host for this episode, Rachel Day.

Susannah Morgan: At its core, hunger is a result of exclusion, of not having enough food, of not having enough income, of not having enough power, of not having enough voice. Hunger is a poverty issue, and hunger is also a result of systemic inequities like racism and sexism. It is not accidental that people of color are more likely to be hungry, it is not accidental that people with disabilities are more likely to be hungry. It is because our systems are set up to make it harder for some people to succeed. I would also say that another way that we have gotten here is by the increasing gap in income― wealth inequality. In my father's generation, you could work a blue-collar job and make enough to support your family and that's just not true anymore. We have more and more folks who are experiencing hunger and working.

Angela Dowling: We talk about that often when we are with some of your colleagues and in our discussions at the board meetings and so forth. Can you help us understand this inequity issue to a greater degree?

“If we are really are trying to end hunger, then we also have to be looking at the systems that make an un-level playing field for folks and try to dismantle those as well.”

SM: When you look at who is experiencing hunger in Oregon, the largest group of folks who are experiencing hunger are our folks, who are white, as you would expect from the demographics of Oregon. But people of color and particularly African-American folks are twice as likely to be hungry as you would expect from their percentage of our population. Single moms are much more likely to be hungry, and people who are living with disabilities are much more likely to be hungry. We know that we have set up the systems to lead to this result. In the case of folks who are African-Americans, we replace slavery with Jim Crow laws, we replace Jim Crow laws with redlining, we replaced redlining with mass incarceration. We, as a society, have set up systems; not deliberately, I'm not talking about conspiracy theory, I'm just saying that we have set up systems and the result of which has been: that it is much harder for someone with African-American background to gain wealth, and keep wealth, and pass that on through generations. They're more likely to be poorer, and more likely to be hungry.

If we are really are trying to end hunger, then we also have to be looking at the systems that make an un-level playing field for folks and try to dismantle those as well.

Summertime is Hungry Time for School Children

AD: Over the summer, I think food insecurity becomes an even greater issue. Children are out of school, they no longer have free lunch. Help us understand what's happening in that space.

SM: Summer is definitely the hungriest time of the year because kids don't have access to meals at school. Here's the sobering truth, one out of every two kids in K through 12 in Oregon get a free or reduced meal. Those families are deeply relying on the fact that those kids can get breakfast and lunch, and sometimes after school meals, at school to help stretch their budgets and make sure that thier kids get nutrition and then for three months they don't have that access. There is a program called The Summer Food Service Program; which, is the federal program to feed kids during the summertime, but it's a meal program and schools aren't open, so they're offered in sites that somehow these kids and their families have to get to. Here are transportation barriers, the convenience barriers. What do you do if the adults are working and can't take their kids to those sites?

The result is that despite lots of really, really, good folks working in this, it's a fraction of the kids who get meals at school, who get meals during the summertime. So, we always, always, always see a surge in families coming to food pantries and soup kitchens during the summertime to help get those extra meals for their kids.

AD: What are some of the creative things that the Oregon Food Bank and other programs are doing to help over the summer?

SM: Some of the creative things that are happening, in Oregon, as you can imagine, has a real bounty of fresh produce. We grow 200 commercial crops here in Oregon, and starting now with the strawberries, we're going to have lots, and lots, and lots of locally grown delicious food. We have a bounty of fresh foods in the food banking system, especially during this time of year. The Oregon Food Bank, and our regional food bank network arrange to do extra distributions of fresh produce. Those produce distributions may happen alongside a meal site where the kids already are. It may happen in a neighborhood that has a lot of kids or at a low-income housing unit. They may happen along with a health clinic or alongside the DHS office where folks are coming to access benefits.

At this time of year, we will see lots of extra distribution that way. We also work very closely with Partners for Hunger-Free Oregon; which, is another non-profit that offers lots of startup grants to folks who want to start those summer meal sites. Those are also ways in which we're encouraging more work during the summertime. We are always working to pull away stigma, to make it easier and more comfortable for people to get food assistance.

“We encourage people who need food assistance, to volunteer at food assistance sites. Those folks will go back and tell their community, ‘This is a safe space, I've been volunteering there.’ They will be the best advocates and resources for their community."

SM: One of the most obvious things that we have done is encourage people who need food assistance, to volunteer at food assistance sites, because when you draw people who need food assistance into your volunteer pool, you automatically get cultural competence. You usually get linguistic variety, you'll get people who need the food being part of the decisions about how the food is distributed.

Those folks will go back and tell their community, "This is a safe space, I've been volunteering there." They will be the best advocates and resources for their community. That has been a best practice that we have been promulgating as well.

AD: I love that idea, because, back to your comment earlier around inequities, and challenges for people to be able to access the food even if it's available, is the stigmatism. We don't always know what they're feeling, or thinking, or what's culturally appropriate for that audience. Being able to bring them in allows you to learn from that and then, as you said, draw other individuals who are also struggling with that issue from their community into getting the food that they need.

SM: I think the fewer decisions you can make for other people, the more likely you are to successfully meet their needs.

AD: There was something I've learned recently that with food deserts that exist – and I think many of us know what that is in terms of not having access to nutritional food, non-processed food – is that a lot of individuals don’t know how to cook in that environment. If you give them fresh produce or you give them access to vegetables that maybe they haven't seen before or haven't had access to, they don't know how to prepare that food. What is the Oregon Food Bank doing in that space?

SM: Our theory of change around how do we get healthy food to lower income folks is kind of three nested circles. The outside circle is first you need access to it, you must be able to find it and afford it. Of course, we can create access to these healthy foods through our produce distributions. The second circle is that you have to choose it, so if there are apples and rutabagas at the food pantry, you have to take apples and rutabagas home. The third piece is that you have to eat it, it has to go from your counter into your belly. We can affect the access to it through our produce distribution, we can affect the choosing of it through a couple of different ways; one, we can do it through an intensive education program. We have a Cooking Matters program which is a six-week cooking and nutrition education, and grocery shopping on a budget program for folks who need deeper skill building and would really like to build the community around their skills in food.

There are also little interventions. We find that if we can create opportunities for people to share ideas among themselves, among people who are needing food assistance, that we often don't have to intervene ourselves. Putting out recipe cards is an idea, but an even better idea is having the Russian grandmother who knows what to do with rutabagas, talk to the rest of the Russian community about her recipes for rutabagas that also work within her culture. Creating the spaces and opportunities, identifying the people who have those skills and lifting them up as peer mentors, peer teachers, has been a wonderful way.

“We find that if we can create opportunities for people to share ideas among themselves, among people who are needing food assistance, that we often don't have to intervene ourselves.”

SM: I think another thing is just assumptions. We would assume that rutabagas are hard to use because in the WASP middle-class culture that I grew up in, rutabagas weren't common, but that is not true for all cultures. To sort of pull away your own assumptions and say, "Wait, is this actually a challenge?" And if it is, we should create some solutions around it, but let's not pretend it's a challenge, let's know that it is. I have a great parsnip story, a couple of years ago we got in 18 truckloads of parsnips.

AD: Eighteen?

SM: Eighteen truckloads, and we start pushing our parsnips out through our system, and we put in recipe cards, and we put in cooking demonstrations, and it was still really hard to finally get all those parsnips out before they went bad. When we got it done and we thought, "Oh, okay we're never going to do that again." And then a year rolled around to about the same time the parsnips came in and we started getting phone calls, “Where are the parsnips? Where are the parsnips?” People had learned how to use parsnips, and they were excited about getting parsnips. I think about me, I'm a cook, I like to cook and getting a CSA box and it has a sunchoke or kohlrabi or something that I'm not familiar with, well once you get a recipe that you know that you like now you know what to do with sunchoke and kohlrabi. Once you get a recipe that you get about parsnips, now you know what to do with it. It's sort of this high initial barrier, and then very easy there afterwards.

Incorporate Food Insecurity Screening into Institutional Workflow

AD: What are some other innovative programs that the Oregon Food Bank is implementing? We talked about a lot, but I'm sure there are some others that others would feel wonderful learning about.

SM: I'd love to brag on the Screen and Intervene Program. Seven years ago, the Oregon Food Bank and the Childhood Hunger Coalition jointly developed the idea that when someone comes to the health care provider, they could be screened for food insecurity. It's two simple questions about whether you're having trouble getting enough food for your family. Then if you screened positive, was there an intervention? Was there something we could do to improve the food security for you and your family? We piloted that at OHSU over the course of a year and we learned a couple of things.

  1. That it's really hard to get into health record system, but you can do it if you're determined enough.
  2. That nobody minded being asked about whether or not they were hungry at the doctor's office, I mean you're already going to be asked, you know, about sex and a whole bunch of other embarrassing things at the doctor's office. Hunger wasn't a difficult thing.
  3. That the provider who was seeing you, the doctor or RN, would not have otherwise known which of their patients might be experiencing food insecurity.
  4. That once they know that someone was experiencing food insecurity, sometimes they change their mind about what that meant about your health. Is your blood sugar high because you are pre-diabetic, or is your blood sugar high because you've had nothing but white bread to eat for four days, because that's what your family has access to? The solutions should be different.
  5. We could customize an intervention for each clinic. From places like OHSU that have all the resources in the world, who can talk to a case manager, and get signed up for SNAP or WIC, but also to small rural clinics, where it's a list of your local food pantries.

We've gone from that one pilot seven years ago to now we have almost 400 clinics across Oregon asking the screening; screening more than a million people a year. We are finding people who need food assistance and don't know where to ask, and we are catching them, and we are getting them into places where they can get help with their nutrition. That just makes me sleep better at night. I know that they are getting better health care because their doctors and nurses understand this is a challenge for them and are seeing their whole health with food as part of the social determines of health, and nutrition as part of the social determines of health. I know they're getting better health care, they're getting more nutrition, they're getting better health care. What really lights my fire is the fact that we now have doctors and nurses and other providers all over the state who are starting to see the connections and starting to stand up and advocate for a hunger-free Oregon; which, is how we're eventually going to put the food bank out of business.

“I know that they are getting better health care because their doctors and nurses understand this is a challenge for them and are seeing their whole health with food as part of the social determines of health.”

AD: I love that. I love the passion that you bring, and that raising awareness for providers to start to ask these questions, to then allow them to have access to food and where to go afterwards, right? As a health care company, you can imagine that speaks to us as well, and to our heart and soul in trying to keep people healthy, get people healthy and then keep people healthy, we have to do that with nutrition. It has to just be the underpinnings of what we deliver as a community, so that speaks to us, and to me personally, obviously. Let's talk a little bit about the FEAST (Food, Education, Agriculture, Solutions, Together). This is a program that's been in place and that we co-sponsor. What can you tell us about the Feast Program?

Empower Communities to Make Change

SM: The FEAST Program is built on the idea that communities don't need to wait for elected officials to make change. That communities have the power to make change themselves. FEAST is a model of organizing communities around a food system to make a specific change in their food system. We spend months getting the right people in the room, the mayor and the principles of schools and the growers and the master gardeners and the grocery store owners and everybody in the room. Then we say what's working and what's not about your food system, and that can be from the growing of food, to the distribution of food, to access, to food, the whole nine yards, the food, and generally about how does food work in your community. They spend the morning talking about what's working, what's not, then they have a brief hour or so in which we say, "This is what's worked in other communities, these are the things that other communities have picked up as projects."

Then they spend the afternoon deciding what project they want to work on in their community, and it's the intersection of a good idea, and where there's energy. Maybe not the very best idea, but the good idea, and where there's energy in the community to do it, and they land on that, and then we give them a resource. We give them AmeriCorps for a year to get that project underway.

“There's so much power in just organizing people around an idea, and then putting time and energy into that idea.”

Then after 15 years of doing this, many of them are in partnership with Cambia or Regence, we can say, "That community saved their rural grocery store and now there's still groceries in that community. That community rebuilt the bridge, so the farmers could get their food to market. That community made it possible for local produce to make their way into the supermarket. That community started the first food pantry in a 50-mile radius. That community figured out how to have a farmer's market started in a rural community."

It almost gives me chills, because there's so much power in just organizing people around an idea, and then putting time and energy into that idea. All these great things popping up all over the state through this collective work.

Observing Childhood Hunger Leads to Life Mission

AD: Susannah, tell us how you've gotten involved from the very beginning around food insecurity and why this is so important to you?

SM: When I was 14, I was in a kid's theater production, and on the night of the dress rehearsal I was standing on stage after the rehearsal in my costume talking to the assistant director who was a college student at Wesleyan University in Middletown, Connecticut. Holly was her name, she told me that she had a scholarship for tuition, but that all the rest of the money was going to her room and books. So, in order to eat, she would go through dumpsters and pick out cans and recycle them for 10 cents each. I had never met anyone who was so close to poverty, so close to hunger that they had to resort to going through dumpsters for cans.

I started crying and I have this vivid, visceral memory of standing on stage crying in my costume. My mother came to pick me up, and she calmed me down and she said, "Honey, I'm so glad this upsets you, what are you going to do about it?"

AD: Wow, I love your mother.

SM: My entire career is my response to my mom. Why did you join the Oregon Food Bank board?

AD: I joined the board for several reasons. One, I understand the importance of food. I'm a mother of three, and food is very important in our family, and I have grown up on a farm, so I understood the importance of food throughout my life. Food is important to all of us, right? It's integrated into what we do, but having come from a farm-family, seeing how important it is, watching my grandmother prepare food, and then watching my kids eat food, and be part of that, I just understand the core essence of how important food is to everybody. I know that there are those individuals out there who are not as fortunate and can't go to the grocery store and buy apples and so forth and good nutrition food. Then being in my role, obviously, as president of a health plan I understand that part of our obligation as a health plan is to help people be healthy. But you can't be healthy if you can't eat, because of all the reasons that we had talked about.

To be your very best, you have to have nutrition and if we can be part of that, that would be success for me. That's why I joined the food bank.

Leslie Constans: That was Angela Dowling, the president of Regence BlueCross BlueShield of Oregon and a member of the Oregon Food Bank board. She was joined by Susannah Morgan, CEO of the Oregon Food Bank. That wraps up this episode of HealthChangers. You can find more information on more of our episodes at CambiaHealth.com. You can also follow us on Twitter @Cambia. Please subscribe to HealthChangers on Apple Podcasts or Stitcher and leave a review. Thanks for listening.

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