How would education change if we treated educator
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and student wellness isn't optional. It's foundational.
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.com. Stay well. Welcome to Season 4, Series
3 of Questions You Didn't Ask. I'm Nyisha Frey,
CEO of Nyisha Frey Consulting, LLC, where we
design community -informed solutions to health
equity problems and shine a light on the questions
that too often go unasked. This series is called
Beyond the Band -Aid, Prevention, Power, and
Public Health Equity. And I am thrilled to be
joined by my longtime friend, former UNC Gillings
classmate and fellow believer in justice -centered
public health, Dr. Paul J. Fleming. Paul is an
associate professor of health behavior and health
equity at the University of Michigan School of
Public Health, a committed researcher and educator,
and the author of the powerful upcoming book,
Imagine Doing Better, Why Policies Backfire.
and How Prevention Thinking Can Change Everything,
which you can pre -order now through bookshop
.org or directly from Hopkins Press. Paul and
I first connected as doctoral students in the
Department of Health Behavior at UNC Chapel Hill,
bonding over big ideas, shared curiosity, and
a drive to change how we approach public health.
His journey from growing up in Glen Ellyn, Illinois,
to working on Medicaid policy, to serving in
the Peace Corps in Nicaragua, has given him a
front row seat to understanding how poverty,
politics, and power shape the health of entire
communities. Paul's framework for prevention
thinking is both simple and radical. It starts
with root cause analysis, asking why problems
like violence, chronic illness, or educational
inequities exist in the first place. Then it
prioritizes primary prevention, stopping harm
before it begins. And most importantly, it centers
the voices and needs of the people most impacted.
Paul draws inspiration from the disability rights
movement's powerful principle, nothing about
us. Without Us, a rallying cry from South African
disability activists that emphasizes the right
of impacted communities to shape decisions affecting
their lives. Here's why this conversation matters
now more than ever. Chronic illnesses make up
90 % of America's $4 .5 trillion healthcare costs,
draining $168 billion in lost productivity each
year. and projected to hit $2 trillion by 2050,
according to Centers for Disease Control and
Prevention. Racial and ethnic health inequities
cost the U .S. economy $451 billion in 2018 alone
and could top $1 trillion by 2040 if left unchecked,
according to the National Institute of Health,
as well as Blue Cross Blue Shield of Massachusetts.
Meanwhile, current federal proposals could slash
over $1 trillion for Medicaid, putting 10 to
12 million people at risk of losing coverage,
closing rural hospitals and forcing families
to choose between food and life -saving care,
according to reports by Axios and the Wall Street
Journal. These are not just abstract numbers.
These are the lived realities of our neighbors,
friends and families. In this series, we're asking,
what if we stopped patching broken systems and
started building ones that heal? What if we rewarded
care instead of punishment? And what's possible
when we lead with imagination, equity and collective
action? Whether you're a student, policymaker,
health professional or community advocate, this
series will challenge you to think differently
about what public health can be. and how we all
have a role in creating it. If you want to follow
Paul's work, pre -order his book, or subscribe
to his thought -provoking newsletter, visit pjfleming
.com and pjfleming .com slash newsletter. You
can also find him on LinkedIn and Twitter at
pfleming3. Let's move beyond the band -aid and
imagine what's truly possible in this discussion.
Paul, you know, we have been looking forward
to this conversation for quite some time. Oh,
my goodness. I'm so glad to have you with me
on questions you didn't ask for the first time.
I'm not going to say it's the last. Well, I'm
excited to be here. Great. Great. So share with
me and my audience. Why? Why did you agree to
be on this show? Questions you didn't ask. Well,
of course, I would want to be on this show. You
know, one of the things I think listeners should
know is we go way back, right? So I remember
some wonderful conversations that we had when
we were in grad school together. And I've been
seeing and listening to your podcast ever since
you started it. And so the invitation and opportunity
to come chat with you again on here, I couldn't
pass it up. I agree. I agree. That's one of the
things I've been looking forward to. And it's
just nice that we get to share these conversations
more broadly because, you know, we have a lot
to share and a lot to say about some really important
topics that I think our audience is going to
resonate with. But before we get into our expertise
and our secret sauce, let's start with who you
are and how you got here. So tell us about your
path from growing up. to becoming a professor
at the University of Michigan Go Blue School
of Public Health? Thank you. I'm impressed to
hear you say Go Blue as a as a Tar Heel fan.
It happens. Well, you know, that's such a fun
question to start with, because I think, you
know, oftentimes we don't take the time to really
get to know each other's origin story. And I
don't know, maybe we did talk about it back in
the day, but, you know, here's an opportunity.
So I grew up outside of Chicago. I grew up in
a suburb of Chicago called Glen Ellen. And, you
know, it was a well -resourced environment. I
didn't realize it at the time because it was
just all I knew. But as I went on in my career
and my life, I realized just, you know, how many
resources were there available to me. i went
to public schools that you know by and large
had the resources they needed to help students
succeed and you know from there i went on to
the the state public university university of
illinois another big ten school and And I studied
political science and I studied Spanish. And,
you know, I was thinking I'd make a career somewhere
in the public policy realm. I wasn't really sure.
I didn't have a topic I was interested in. I
wasn't really sure. But I thought, you know,
I'm interested in government and politics and
those kinds of things. And I'd love to be a part
of the policymaking process. And along the way,
I, you know, I always and I think growing up,
my parents instilled in me this you know this
this desire to give back and and participate
in your not only participate in your community
but kind of give back to the community and and
help your help people that are less fortunate
than you etc and so since i had been studying
spanish the peace corps was something that was
present in my mind as i was going through college
of this would be a really interesting opportunity
to use the spanish that i've been learning work
in communities, helping them thrive. And I was
really eager to live outside the U .S. at that
point. So even though I kind of had public policy
in mind, I took what I thought was a little bit
of a detour. I joined the Peace Corps. I spent
two years as a community health volunteer in
Nicaragua. And that really just... That changed
everything for me. Of course, going to college
and getting out of the place I grew up also exposed
me to a broader range of experiences in the US.
I met, you know, met types of people that I hadn't
met before. I learned more about rural communities,
urban communities, people growing up in all different
settings. Right. So that was part of my college
experience. But then really. going to be a Peace
Corps volunteer and living in what was at the
time the second poorest country in the Western
Hemisphere was was really just eye opening in
the sense of you really saw what you saw, how
communities came together to support each other
in a way that I didn't always see in my community
growing up because the resources were there and
provided for. You know, I think you really see
what poverty what a negative impact poverty has
on people and also the the happiness and the
you know the talents and everything of communities
that are living in poverty and through that work
though i was assigned to be a community health
volunteer now i have to tell you naisha before
that moment i did not care about health at all
i was the person who you know, didn't really
like being around blood or anything like that.
I didn't particularly care much about health
issues. I think if you asked my friends, they
wouldn't think I was particularly healthy or
making very healthy choices for myself. So in
a lot of ways, health and now my whole career
in public health, it wasn't always an obvious
place for me to go. But with the Peace Corps,
they saw my background, they saw my Spanish speaking
and And I did at one point do a public policy
internship that had something to do with Medicaid.
And so they said, oh, Medicaid is health. Why
don't you go be a health volunteer? And so so
that anyways, I worked as a community health
volunteer. And in the Peace Corps, you partner
with local communities. You only go to communities
where you're invited in. So these are a lot of
lessons that I carried forward. Right. Of like
the partnerships. The people have to want to
be working with you. You can't just impose yourself
upon them. And then also, you know, you're working
in partnership. It's not just the Paul Fleming
show trying to go do work in this community.
I'm asking questions. I'm learning what the priorities
are. I'm following other people's leads. So that
was really, you know, that was as we get into
my public health career, that was the foundation
I was starting with. And I learned that I really
love this thing called public health. Like the
opportunity to work in partnership with people
to help people be healthy. It was at that moment
I also learned that health isn't just about disease.
It's about thriving. It's about helping people
have the resources they need. It's about education
and transportation. And it's about all these
different things. And I really credit, you know,
one of the Nicaraguan women I worked with was
named Xiomara. She taught me all of that. And
she was actually kind of a revolutionary in her
country. I mean, a literal revolutionary participating
in a revolutionary war. And she taught me this
ethos of health as a human right and this ethos
of working and building relationships with people.
And all of that really stayed with me. And so
anyways, I dwell on that Peace Corps moment because
it taught me so, so much. And from there is when
I said, you know, okay, I've learned a lot from
this experience, but I would like to get some
formal training in public health. And so I went
on to do a master's degree. And then at that
point, I sort of realized that research was,
and public health research in particular, because
not all research necessarily works this way,
but public health research is an opportunity
to do community work and really help partner
with communities to uncover. what's going to
work well in this community? What doesn't work
well? How can we take those steps forward together?
So that was the type of research that I was really
eager to learn more about. Sometimes we call
that like community -based participatory research.
I did some training in that. And then as I did
more and more work, I was working with immigrant
communities in the U .S. I was still doing a
little bit of global health work. And then more
and more today, I've started doing work that's
partnering with public health institutions, thinking
about how you embed equity into that work. And
so I know that's a long winded answer. And it
was supposed to be. Yeah. But I really think,
you know, where I started, starting from a place
where I did have resources and then having the
opportunity, either through my training or through
Peace Corps or through different jobs that I
had over the years to really see. the wide range
of the human experience and what people are facing
and just learn more about just how many communities
there are in the U .S. throughout the world that
don't have the resources, right? And oftentimes
those things are connected. The fact that my
community had resources was connected to the
fact that another community didn't because we
weren't distributing those resources equally,
right? And so as I came to understand that my
privilege was connected to other people's disadvantage,
that really motivated me of like, this is what
I want to dedicate my work to. And I know, I
mean, I'm not going to solve it alone. I'm not
going to be able to tackle it alone, but this
is the area I want to work in for my whole life.
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your continued support and let's keep the conversation
going. I mean, it is a lifelong journey if you're
going to, you know, completely follow your heart
and your spirit to do this work that is not mainstream,
is not popular. but is so needed, you know? And
some of it is a part of, I know for me, what
makes me feel alive and what makes me feel human.
And I definitely get that from you. I'm so glad
that you talked about, you know, how these different
experiences exposed you to different communities
and that it kind of stripped away a lot of things
that, like you said, you took for granted. You
know, that's natural. I always... sometimes call
that process of like what it is to be in innocence.
I didn't realize that innocence is like in no
sense. You did not know. Right. These are things
that you just did not know as a child, as an
adolescent, as a young adult until you became
or you had some sense. Right. You gained some
sense, some perspective. And the sense is. Not
just knowing, but it's also touching, feeling,
hearing, hearing, a lot of hearing, speaking.
All of those senses, you know, have been activated
in you. And so through that process, your whole
life outlook changed. And that's just really
powerful. Yeah. And I think those types of experiences
can be all around us. We have we have to be open
to them, you know, and I think that was the in
some ways the beauty of the Peace Corps experience
is they the Peace Corps itself really trains
you and sets you up saying you don't have the
answers. You don't know. You better go in there
and listen, listen, listen, listen. Right. And
so, you know, it helped really just open myself
up to being able to hear it, because I do think.
especially as we go through our day -to -day
life and if we're distracted and other things
you know there may be these powerful experiences
waiting in front of us but if we're not open
to it we're just going to keep moving forward
in the same way so speaking of moving forward
in the same way and oftentimes getting caught
up in what it is that needs to be done you know
i think It's important to call attention to the
fact that you are a white man. You are what we
consider a heterosexual cisgender man, meaning
you were born male and you live as a man. That
is your identity. And you are those things in
America. You know, that is the first thing that
someone is going to notice about you, whether
they have the privilege of talking to you and
getting to know you or not. And because of that,
that shapes the world that you engage with and
interact with. But just from your own words,
how would you describe how your identity has
shaped you and how you see the world? And specifically.
Yeah. Let's start there. Let's start there. How
has it shaped you and how you see the world?
Yeah. And I mean, that's another big question.
You're good at throwing the big questions my
way. And I know they'll keep coming. But yeah,
I mean, of course, our identities really do shape
who we are. And so I think, you know, being a
white man and that's the other thing, right,
is. the way that whiteness can be invisible in
this country, right? To be white is almost to
not be racialized in the same way that other
groups are. And so, of course, I am racialized.
I am racialized as white, but I'm just saying
culturally, we think of whiteness as like the
absence of race. Or the default. Right, the default,
exactly. The baseline. And so, frankly, I didn't...
think a lot about my whiteness growing up. My
town was definitely majority white, vast majority
white, but not exclusively. There was definitely
some diversity of racial and ethnic identities,
but it wasn't something that was talked about
much. It was very much the sort of default race.
It wasn't something that I reckoned with. I thought
a lot about, to be honest. So it has really been.
a journey for me to recognize that I am racialized,
I live in a racialized society, and that whiteness
is, you know, privileged and advantaged over
other racialized groups. And so even seeing the
lens in which the town I grew up in, right, that
it was well resourced because it was predominantly
white, you know, or that those things are connected,
right? And that other communities that are not
predominantly white. and are not resourced, it's
partially due to that fact, right? So reckoning
with that. And then I think being not only just
white, but a white man in our power hierarchy,
that is the pinnacle, right? So I think reckoning
with, and that, yeah, I mean, just to be frank,
you know, that it feels uncomfortable. I'm not
trying to be at the top of the pyramid. I'm not
trying to... to hold that, but it's a reality.
And so I think over the years, I think I've done,
I've tried to do a lot of work to understand
that, understand my identity better and where
it fits in. And then I think the other thing
is, and I didn't mention this earlier, but actually
when I was getting started in public health work,
some of the work I was working on was work directly
with men around masculinity and the ways that
masculinity can. encourage men to choose behaviors
or do things that are harmful to themselves,
to their partners, to their community, you know,
being violent, things like that. And so that
process alone really helped me unpack masculinity
and patriarchy and really think deeply about
that. But frankly, I kind of went through that
journey before I really went through a journey.
thinking deeply about and trying to unpack my
race and racial dynamics in our society. But
in some ways, thinking about it through a gender
lens first really helped give me the tools and
some of the language to think about how these
social structures of gender and race do create
power hierarchies in our society and that those
power hierarchies are harmful. And so that was
a process that I had to go through. And, you
know, I can't separate my identity from the work
I do. I am a white man doing work on health equity.
Much of my work partners with people in communities
that have identities that are different than
mine. And so I think from that lens, one of the
approaches I take is back to, you know, a lot
of listening and a lot of relationship building
and a lot of... not trying to put myself at the
forefront, but rather understand what other people
think is needed and then see how I can support
moving that work forward. And I can't say that
I do that perfectly all the time. Absolutely
not. But that is, I think, you know, a place
I've come to. And I think how my identity as
I do this equity work comes into play. Yeah,
I asked that question because, you know, commonly
we talk about terms like intersectionality, right?
And we usually talk about it from the framework
of, you know, the original author who is a Black
woman. And one of the spins that I like to take
on this concept of intersectionality is that,
you know, even though it does help us to unfold
each layer of our identity, right, which depending
on who you're talking about, comes with a certain
level of disadvantage right but what i've noticed
and i should say and what i've noticed is that
when you take that concept and you place various
individuals in different settings in different
communities what was a disadvantage can now become
an advantage what was a privilege can you know
can turn into the opposite right and i find it
interesting First, I'm thankful that I have a
friend like you, Paul. And I will say it, you're
not the only friend, but you're a part of that
community of friends of people who happen to
be white. And I make that classification because
there's a lot of negative connotation that comes
with the white community in general, writ large,
right? There's some unfortunate patterns that
are associated with. the white community writ
large especially from a political sense so when
i think about people in my community that i can
have these conversations with and be honest about
i'm thankful for that because it allows me to
dig a little deeper and have more understanding
have a different share my perspective but also
like you said listen and learn and be able to
unpack some of that stuff. And I think that it's
really interesting too, that you talked about
how better understanding your maleness, your
masculinity, and not just yours, but what it
is to the greater population. What are those
kind of common characteristics that we associate
with masculinity, whether that applies to you
as an individual or not? Going through that practice
and that study gave you some tools and potentially
some humility that allowed you to dig a little
deeper when it came to unpacking whiteness and
how your white identity or your whiteness or
however you want to call it has shaped your privilege
and has shaped your opportunities. And even though,
like you said, these things that we experience
is not what we sign up for. You know, like you
talked about, I didn't I'm not asking to be at
the top of the heap, but because of this society
and this culture and these labels and these values
that we've placed on our identities, it's there.
Right. Like I didn't sign up to be discriminated
against because I'm a black woman, but it's there
and I have to deal with it. And what am I going
to do with it? And so that becomes the question.
Yeah. Well, that point about what are you going
to do with it? I mean, I think that's the other
thing that. in a way motivates me is because,
I mean, I'm pretty clear that part of the ways
that I get to be a professor at the University
of Michigan is because of privileges that I've
had over the years, right? And so Being a professor
at the University of Michigan also comes with
some power, not nearly as much power as I would
want. Right. But you have some. You have got
no magic wand. Right. Exactly. You have some
decision making. Right. You participate in decisions
about admissions and scholarships. You participate
in what the curriculum looks like. You participate
in reviewing grants for what types of things
get funded. And so if I'm not. If all of us aren't
intentional about using the power that we do
hold in ways that advance equity, that make our
society better, that lift up people that are
disadvantaged, then we're doing it wrong. I'm
taking up space from somebody who could do that
work, right? And so I have to be very cognizant
of that, of the position that I hold. which is
connected to my identity. And then what am I
doing with it to undo those systems that gave
me those unfair advantages? So, Paul, you and
my people, my people who happen to be white,
my community of brothers and sisters in this
fight to advance health equity. And unfortunately,
it is a fight. I hate to say it. It's a fight
because there are way too many people who don't
try to change anything. They're completely fine
with the way things are. Actually, they'd rather
fight you to keep their position of power and
privilege and ease, right? I mean, I can only
imagine. Like if you wanted to maximize, for
those who do maximize their whiteness, who do
maximize the privilege of maleness, who do maximize
the privilege of being white, male, and heterosexual
in this society in America, like they've got
it made in the shade, man. Made in the freaking
shade. Why would you want to give that up? So
I've got to ask you, I mean, just go there with
me and my audience and tell us, why does health
equity matter to you? I mean, I'm struggling
to find the words because it is one of those
things that it's hard to, it's hard. I mean,
I think those of us who are in it, it's hard
for us to imagine, well, why wouldn't you care
about this, right? So that's why I was stumbling
a little bit at first, but I think it matters
to me because I know I'm connected to it. I think
some people who are in the position of advantage
don't see themselves as connected to those who
are disadvantaged, right? Those who are disadvantaged,
whatever's going on with them is their own thing.
For me, I'm very aware that all the advantages
I experience as a college professor, I'm not
wealthy, but all the wealth that I experience,
all the resources I have at my disposal, those
are connected to the systems and they're connected
to the disadvantage that others experience right
so a simple example of this right like i save
money on my grocery bill because there are people
and workers who are under class getting low wages
in this country to pick the fruits and vegetables
they're not having their human rights protected
they're not earning a living wage And right now
they're being, you know, disappeared and deported
and other things that are horrible. Right. But
for me to sit here and pretend that I'm not connected
to that system that has created that is just
not true. Right. And that's just one small example.
And so given that I'm connected in these different
ways to harm that is occurring to other people.
I feel a responsibility to do work that is trying
to change that system. And I think that's part
of what lights the fire under me. And that's
why I care. And I think, you know, for a lot
of people that don't care, I do think it goes
a little bit back to that innocence comment that
you made earlier. Some people just haven't had
the opportunity to see the ways in which these
systems work and they're connected or they're
not even really aware. But I think you're also
right that some people see it and they just want
to hold on to the power. And so I think that's
a different challenge for us to deal with in
society. But I think, again, part of maybe how
I was raised is you share. You want to share
with other people, right? If I have stuff, I
want to make sure other people have stuff too.
If I have safety, I want other people to have
safety. If I have an opportunity, I want to make
sure that other people have an opportunity. Yeah.
And that ripple effect. I mean, I think that
it's interesting that you talked about, you know,
your time at Peace Corps. And granted, you saw,
I'm sure, I've never been to Nicaragua. I've
been to other countries that are considered third
world. And I've seen different levels of poverty
in other countries and in the United States that
blew my mind, right? And I didn't grow up with
a lot of money. I grew up either very, very poor,
you know, but I've seen people that grew up worse
off than me, right? Like, I was like, dang, I
thought we were struggling. Dang, that's deep,
you know? And when you talk about that, you made
sure to share. And I believe that you're sincere
when you say this, because I've witnessed it
myself, that the happiness wasn't necessarily
contingent upon what you had in the bank or what
you had on your label you had in your clothes.
The creativity, the intelligence, the wisdom
was not tied to those things. And I think one
of the things that can set people apart in seeing
that sharing, not having all of it, not hoarding
it, hoarding it doesn't make you happy. Hoarding
it doesn't necessarily make you have a better
life. Sharing it and making sure that you have
people to enjoy it with you, right? And making
sure that everybody has something and we have
people around the table with us. that tends to,
in my experience, and I would love to hear your
perspective on this, but in my experience has
made me feel rich. Yeah. I think you said it
so well is that, you know, if we're thinking
about as individuals, like what is going to make
us feel like we have a happy and fulfilling life,
then Yeah, the accumulation of money and things,
it's not it, right? What makes us as humans feel
happy and joyful is the connection. It is the
community. And so I think in a capitalist society,
we sometimes forget that the thing that we want
to maximize is actually happiness and joy. Because
in a capitalist society, a lot of us, including
myself, get stuck on the thing we want to maximize
is the money. I need more money. I need more
money in my bank account. You know, if you stop
and think about it, money doesn't equal joy and
happiness. What we want is joy and happiness.
And I think back to what you were saying about
my experience in Nicaragua, you know, a lot of
it is seeing the humanity in people. especially
the way sometimes our news media works or the
ways that we're isolated from each other in the
U .S. Your vision of a different community than
your own is often some sort of stereotype. It's
often some reduced idea of what that community
is or isn't. And the reality is no matter what
human community is, there is pain and there is
joy. There is creativity. There is hard work.
There is the range of human experience within
that community. And I think, you know, we do
ourselves a disservice when we think we allow
ourselves to think of a different community as
somehow not as complicated as our own community
or our own family or our own experience. And
so absolutely people who are living in a lot
of poverty. Some of them were super happy and,
you know, and they made do. Right. They were
like, this is what I have and I'm going to do
my best. Now, don't get me wrong. Those public
health impacts we know about hurt them. Right.
Like they experienced more health issues. Their
family members died earlier than other people.
Right. So it's not to say I'm not saying that
they were just. happy -go -lucky people that
were always happy. That's not at all what I'm
saying. But the point being is that that happiness
and joy and the ability to experience it is human.
And so we all experience it at different points.
And what we want to do is we want to maximize
that. And I think people who are experiencing
poverty or discrimination, they have fewer opportunities,
but they still persevere and experience it. And
that's a wrap on this episode of Questions You
Didn't Ask. I'm Nyesha Frey, and wow, what a
powerful start with Dr. Paul J. Fleming, his
insights on prevention, public health, and equity.
Pure gold in just the beginning of what's to
come. Don't go far. Join me next time as we keep
pulling back the layers in our series, Beyond
the Band -Aid, Prevention, Power, and Public
Health Equity. I'll see you then.