Sarah Gareau, DrPH, MCHES – Senior Research Associate and Maternal & Child Health Policy Analyst, University of South Carolina’s Institute of Families in Society

Interview Questions

[OnlineEducation.com] Let’s start how your work is situated within the larger realm of public health. You’ve worked in several areas, from research and policy to community advocacy and organizational leadership. How would you characterize your current work at the Institute of Family and Society (IFS)?

[Dr. Gareau] I’m a maternal and child health specialist with a focus on health policy. The IFS Division of Integrated Health and Policy Research is partially funded by the South Carolina Department of Health and Human Services. A lot of people don’t realize just how prominent a role Medicaid plays in moving public health forward. Certainly, they understand about the Affordable Care Act (ACA) and the idea of improving access to healthcare for those who may not otherwise have that access. But, behind the scenes, Medicaid is responsible for pushing through a lot of quality improvement initiatives, providing people with access to primary care, and funding many concurrent agencies. For example, in South Carolina Medicaid helps to fund the Department of Health and Environmental Control and the Department of Alcohol and Other Drug Abuse Services.

The IFS is the 4th oldest University-Medicaid Partnership in the nation. We provide technical assistance and consultation to the state. We have Medicaid data going back longer than any other entity in the state, and we use that data to evaluate health initiatives that have been and are being implemented at the state level and assess their impact on communities within the state. My role, specifically, is to help evaluate some of the projects that have come through state-based coalitions, one of those being the SC Birth Outcomes Initiative, which works to improve maternity care and pregnancy outcomes. One of the others is called Healthy Outcomes Plan, which is the state program that supports hospitals and community partners providing care coordination for the uninsured.

A lot of what we do is data analysis. We use complex datasets from multiple data sources and translate that at multiple levels for policy makers so that they can more effectively improve public health. We are using data to help policy makers visualize public health issues and problems. Ultimately, what we hope to do is provide researchers, policy makers, and practitioners opportunities to collaborate to identify and promote the adoption of policies and practices that are informed by research. In doing so, we’re in a wonderful spot in that we have the privilege of being able to do really meaningful work that might be behind the scenes but that can have a big impact to improve the quality of health care services and health equity in South Carolina.

[OnlineEducation.com] In what sense are you working behind the scenes?

[Dr. Gareau] We are applied researchers, which means we serve as a bridge between the academic world of pure research and the on-the-ground program implementation that happens at state agencies. We have program evaluation and analytics expertise, coding knowledge, computer-based skills, and access to geographic information systems (GIS), which perhaps a state department of public health agency would not have access to. In my case, I have a background in health policy and can help write policy briefs in which we present the implications of the data in a meaningful way.

One of our jobs is to be able to present a clear conceptualization of what has been happening over time in public health in the state and why. That’s an important behind-the-scenes role because, at the state public health agency, in the time that I have been at the IFS, they have had multiple directors, each of whom has had a slightly different vision of how to approach public health, and there have also been a lot of staffing changes. So, we might do things like publish research papers in scholarly journals, but we are more likely to be putting together reports for state public health leaders so that they can move policy forward.

[OnlineEducation.com] Do you teach at the University of South Carolina or is all you work in areas of research, analysis, and policy?

[Dr. Gareau] I used to direct a Master of Public Health (MPH) program in North Carolina but currently I am not teaching because I just don’t have the bandwidth, especially while balancing family obligations during the pandemic. I have done a lot of teaching in the past but right now I’m in a good place where I have a good work-life balance that does not happen to include teaching.

[OnlineEducation.com] Tell me about the MPH program you were involved with in North Carolina?

[Dr. Gareau] It was at a smaller university – Lenoir–Rhyne University – in North Carolina, and they were interested in starting an MPH program. We are seeing a lot more of that nationally. Many of the bigger universities have had MPH programs and now more and more smaller schools are launching programs. Lenoir–Rhyne has also added an online MPH program. I was helping to launch these academic programs about ten years ago.

[OnlineEducation.com] How did you find your way into the field of public health? You got your bachelor’s degree in behavioral science and then you got a Master of Education (MEd) in Health Education degree.

[Dr. Gareau] Yes. At that point what I was interested in was very intervention focused and at the community level, which is the traditional role of health educators. And then I kind of pivoted big time in my career.

My formative experiences were as a health educator in local Boys & Girls Clubs of America in Akron, Ohio, mostly in more vulnerable areas of the city. At the time, we were seeing the direct impacts of the back-to-work policies that were really big in the 1990s. Even as an early career professional doing that kind of work in the community, I could see the impact of what happens when the sole primary care giver in a family is mandated to work outside the home and the effect that that can have on a community.

To back up a little, within public health I think you need people who are community based, working with individuals, and moving the needle at that level, but you also need movement happening at a larger level, which is where public health policy comes into play. That’s why I ended up going back to school – to work more on the policy side of public health.

[OnlineEducation.com] Was your work with the Boys & Girls Clubs something you did after you got your MEd in Health Education degree or was it concurrent?

[Dr. Gareau] We all have different backgrounds, and my personal background is that I didn’t have a lot of financial support for my education. I was working multiple jobs throughout my schooling. While I was earning my master’s degree, I had a graduate assistantship during the day helping to advise students majoring in education. And concurrently, I would also do health education in the community in the afternoons with the Boys & Girls Clubs in Akron. When I graduated from my master’s program, I temporarily became area director at that location, but that was short lived because I went back to school for my DrPH.

I should say that, even before those experiences, my formative experiences as a young adult were centered around the HIV/AIDS epidemic. As an undergrad, I volunteered with a program that served children infected and affected by HIV/AIDS, which is a highly politicized public health issue. So, early on I had an interest in and a passion for political advocacy in the realm of public health. I’m just not sure I realized at the time that it was a thing that you could go to school for and turn into a career.

In an advocacy role, I was initially the face of reproductive health advocacy in our state as the director of an e-advocacy network. Over the past ten years, I’ve moved towards working behind the scenes. It was a big shift for me to start thinking about these issues more intentionally and from a policy perspective. You need grassroots activism, and we want to continue to empower people to work in those areas. But, especially in parts of the country where maybe public health is not at the forefront, we also need to be working higher up in the system to make sure that issues are being addressed at that level.

[OnlineEducation.com] It sounds like you weren’t necessarily aware that public health was a career option. And yet, even as an undergraduate, you were gravitating toward the kind what we would call public health.

[Dr. Gareau] Correct. I think this gets at why it is so important to provide first-generation college students with mentorship. Even as an academically strong student at the undergraduate level, I was never even told that something like epidemiology existed or that you could get a master’s degree in public health. It was only because Kent State was nearby that I became aware of public health. At Kent, they had a doctorate program in health education, only it wasn’t offered through a school of public health, it was offered through a college of education. I realized on my own that health education was what I was leaning towards, but that if you were interested in community health education rather than being a health education teacher, continuing education in a public health program made more sense. So, it was easy for me to see that if you happened to go to a flagship university where, as an undergraduate, you were told about all these things, you started out with a big advantage. For me, it was a much longer journey into the field of public health than it might otherwise have been.

[OnlineEducation.com] Would it be fair to say that getting your doctorate in public health was a way for you to transition from grassroots level health education to higher level policy work?

[Dr. Gareau] I think so. It was a big climb for me. After my doctoral program, I made an immediate jump into running an MPH program before moving into policy work. But everybody is different, and the cost and benefits of further education are different for everybody. For me it had huge benefits. I learned how to move systems and create systemic change, how we better evaluate policies in order to determine whether or not a policy is making a difference, and how to think analytically and logically about those processes. It had a big impact on my thinking and it also opened new doors and created new career opportunities.

[OnlineEducation.com] In your MEd in Health Education program, did you take classes in biostatics and epidemiology that would have prepared you for public health research, or is that something you weren’t introduced to until you got to the doctoral level?

[Dr. Gareau] At the time, Kent State did not have an MPH program. It does now. I remember that the American School Health Association (ASHA) has a presence on campus, and I may have just been lucky in this regard, but they did have us take a research methods class and an introductory epidemiology course. In my cohort of graduate students at the master’s level there were maybe only two of us who were interested in community change and public health, and maybe about 25 of the students were teachers who were interested in learning about health education. I was at that point already interested in big systems change.

[OnlineEducation.com] As you made the transition from health education to public health/epidemiology, did you start to notice gender disparities, particularly in leadership positions?

[Dr. Gareau] I currently wear a number of different hats. One of my hats is that I’m an elected member of the American Public Health Association (APHA) board; another one of my hats is that I helped to form a social media group that is focused on reducing the spread and impact of COVID-19. At present we have about 31,000 members in that group. And I would say that through these different hats, I see the issue of gender disparities in different ways.

One concrete example of what I mean comes from my prior experience with the APHA and simply noticing that we did not have many women represented in the winners of the annual Sedgwick award – The Sedgwick Memorial Medal for Distinguished Service in Public Health. It’s one of the highest honors you can receive from the APHA. For years and years, all of the recipients were men. I don’t think that was purposeful; it just sort of happened. So, myself and another colleague, worked very intentionally on an annual basis to submit award packets for female candidates. We were successful in moving that needle. If you go to the APHA website and look at the list of Sedgewick award winners, you’ll see how that has changed.

It’s also true that the Executive Director of the APHA, Dr. Benjamin (Georges C. Benjamin, MD) has been in that role for a long time. I respect him greatly. At the same time, this is a field that is probably predominantly female. And yet, the APHA itself is not led by a woman. I think you can find examples of this throughout public health. For example, it may be that the director of a state public health department is a woman. But she may still be reporting to government officials and legislators who are men.

There are, even in public health, masculine and feminine stereotypes that you start to notice. You do see a lot of women going into more community-based work, just as I did early in my career. In fact, we know that there are more women than men out there on the ground doing community work in public health, nursing, and social work. We also know that there are a lot of women who are studying public health in school. But, in many cases, the dean of the school of public health, the executive director of a public health agency, and the legislators who have to sign off on public health initiatives are men.

The gender stereotypes in public health have historical roots, and historically public health was dominated by medical doctors who were men. There can still be a top-heaviness in public health where the clinical voice of the MD is valued more than some of the other voices in the field, and many of those voices belong to women. It’s interesting because there are three levels of public health prevention: primary, secondary, and tertiary. Tertiary prevention is where we classify emergency medical treatments and critical-care interventions that come late in the process and are the least proactive. And yet, often it’s the voices of the physicians at the tertiary level that dominate the conversations we are having about public health.

We see that at the national level. I have immense respect for Dr. Fauci and the importance of immunology and epidemiology. At the same time, there are mutual aid efforts all over the US where individuals are doing community-based work to help others through the pandemic who may be struggling to pay rent or buy food. That’s not what you primarily hear about on the news. The news is all about vaccines and immunology and these other more masculine areas of public health. Public Health Awakened, which is a women-led national network of public health professionals who are currently pushing for equity and justice in how we address the pandemic, is not what you’re hearing about on the news right now.

So it’s important to think about which voices we focus on in our conversations about public health and who those voices belong to. And then there’s another piece that we maybe don’t talk about as much, which is not just the question of whether there are women in leadership positions, but who are the women that become leaders in public health and what is their background. When I ran for the executive board at the APHA, I didn’t know until they announced the candidates, but there was only one woman of color among the six candidates who were also running.

That reflects an issue that those of us in the field should be concerned about. And there are socioeconomic issues to consider as well. The cost of professional development opportunities may be too much for community-based public health workers who, for instance, are doing so much to get people tested and vaccinated right now. As a result, they’re cut off from one avenue that can provide valuable mentorship.

On the positive side, we have been very intentional about creating diversity in the Women’s Caucus of the APHA both in the policy and programming work that we do and among the membership of our leadership. So that is something that can happen with some effort at other public health organizations and in the leadership of MPH programs and at schools of public health.

I am reminded that this is a field in which health equity, anti-racism, and social justice are front and center in our work. But we need to make a better effort to have that represented not just in health policies, but also in the composition of our leadership. And that is not exclusively about male/female gender disparity. So, it’s important for us to take a look at who is being included, who is being excluded, and who are the people in the room when decisions about public health are being made.

[OnlineEducation.com] Was there a particular point or points in your academic or professional career at which you started to notice gender disparities in the field?

[Dr. Gareau] I feel like I became more aware of that as I was getting promoted. Early on, when I was doing community health, I was working with almost all women. Working in South Carolina, where we are ranked very low for female representation in government at both the state and federal levels, gave me a different perspective on that. So, when I was working with New Morning Foundation and helping to advance policy and education efforts related to reproductive health education and access in the state, I noticed that almost all of the people making political decisions were men. These are decisions about funding for reproductive health, access to comprehensive sexuality education, and policies that would harm reproductive justice efforts.

I don’t like to stereotype the South because there is good work being done here by phenomenal people, but there is a good old boys club mentality as well, and if you don’t know how to operate in that environment then it can be difficult to get anything done. I found myself wearing really tall heels and nice suits and curling my hair – things that are not really my personality at all. That can be hard emotionally and mentally, and I didn’t last very long in that role because I felt that I was having to give up too much of what were my core values in order to get things done in that male-dominated world.

I went back to the South Carolina Educational Policy Center, where I was doing very standard program evaluation work. At that time, I was not specifically a data person. But my current mentor at IFS, Dr. Ana Lòpez-De Fede, was able to see something in me and she encouraged me to move more toward working with data. Had she not encouraged me and had confidence in my ability, I’m not sure what would have happened. So I have her to thank because I am far more comfortable in my current role, working more behind the scenes.

[OnlineEducation.com] You worked on initiatives to extend or expand family friendly policies at the APHA. That’s something that seems to be a fairly common challenge in so many fields. By “family friendly” we usually mean policies that reasonably accommodate and don’t discriminate against parents of young children – parents who tend to be but are not exclusively women. What form did that take in your efforts?

[Dr. Gareau] Well, I think there is sometimes an incongruence between the mission of public health and actions in public health. We need to walk the walk. And that is definitely something that I have focused on. So, for example, early in my academic career, I attended birth equity conferences. These are smaller conferences attended by doulas and activists who care about safe maternity practices and who are working to implement change at the grassroots level, like trying to reduce the number of unnecessary c-sections. I do that same kind of work now at a policy level.

At birth equity conferences, it was perfectly fine for a woman to have her baby on her hip, and that was not an uncommon site. There was also easy access to lactation rooms, and there were mindfulness rooms as well.

When I started going to the APHA national conference, they had a lactation center in the main expo area, which was great. But this is a huge conference that takes place across multiple hotels. As a result, you could have your meeting at the Hilton and then have to be running through two or three different buildings in order to get to that lactation center. It was family friendly in the sense that they had thought to have a lactation center, but the lived experience was not as family friendly as it could have been.

The APHA conference planners were very open to having a dialogue about the situation, and we were able to get more sites for lactation and to work with hotels on getting milk storage. That’s just an example of how small changes can make a big difference. It’s interesting because the APHA has a Maternal and Child Health Section and we have the Breastfeeding Forum. And yet, as a person who was in that situation, I did not feel comfortable leaving my infant at home, so I skipped a year.

[OnlineEducation.com] What other types of measures, policies, or strategies would you like to see public health regarding the position of women?

[Dr. Gareau] I think you’re asking about what young women in public health can do. I would start by pointing out that economics and money talk. Much of the work I do in policy is aimed at improving the lives and the health of South Carolinians, but it’s not a coincidence that successful programs also happen to be programs that save the state money.

I realize that I am stereotyping again, but women in public health are often interested in doing qualitative, advocacy, non-profit community work. Because of that, a number of things happen. For one, we don’t see as many women going into areas of public health that are seen as being more masculine – areas such as big health data analytics. Secondly, if you’re used to doing community work and dealing with limited resources, you may not be the best advocate for yourself. I think it’s important to learn how to negotiate and to know your own worth. For example, something as simple as looking up salaries in your field and getting a sense that you should be asking for more can be a big step in the right direction.

I have talked about what it is like to not have effective mentorship, about not even knowing that public health existed, or not being sure about how to submit an abstract to a conference – these were things I knew nothing about. These are things that good mentorship can address. It’s the same with knowing what your career options are and maybe having someone tell you that you should skip the lower-paying post-doctoral fellowship and go right into a higher paying faculty position. And maybe you should go ahead and take that class in computer programming or economics or advanced statistics because it will give you a leg up. So, I would like to see the public health field broadly improve mentorship.

I tell people this all the time: what we desperately need in the field and what we are constantly struggling to find at IFS are employees who are passionate about the core values of public health who also have these hard-to-fill marketable skills. I can find a GIS specialist, I can find a database manager, and I can find a computer programmer who can provide the analysis that we need. But it’s hard to find people with these skills who are also passionate about public health, who are prepared to ask the kind of questions that are critical in public health, who have that instinct to question when something doesn’t look right. On the other hand, the people who do get it and who know the kinds of questions to ask and the ways that data can be used to inform policies that improve people’s lives need to be able to do the IT work as well. Those are the people who are hard to find.

It’s complicated. I know that if someone had told me as an undergraduate to take computer science courses, I would have just looked at them and said, “What are you talking about?” But my advice is to do it even if it’s not your favorite thing because the skills you learn will be helpful down the road. It doesn’t mean that you’re going to be stuck in IT for the rest of your life, but you are going to be able to speak the language that can take you further in the public health field.

[OnlineEducation.com] It does seem that the tools used to analyze that data have become more accessible. I wonder if that is going to start making a difference that we are going to begin to see.

[Dr. Gareau] Hopefully that will be the case. It was definitely a much longer path for me in terms of gaining those skills and developing the ability to speak more than one language in the workplace, if that makes sense.

[OnlineEducation.com] It does. To broaden the scope of this conversation, how important do you feel it is to have a greater number of women directing policy, research, and initiatives in the public health sphere and how does that benefit the field?

[Dr. Gareau] It’s difficult to answer questions like that without falling back on gender stereotypes. But we know that it is true in clinical settings that having women in the room results in fewer medical errors. It makes sense when you consider that a woman might have a different perspective that she can bring into that clinical setting. I think the same thing is true in public health research and policy.

[OnlineEducation.com] To bring it back to one of your primary areas of concern, is it fair to say that conversations about reproductive health legislation and policy have a different tone and focus when there are women in the room?

[Dr. Gareau] It is complicated. I want to say, and this is true for a lot of things, that too often we make decisions in healthcare without patients in the room. We make decisions that affect the lives of pregnant women without pregnant women in the room. Some issues, like family care giving, like access to healthcare, like reproductive justice and health equity and housing, are traditionally thought of as women’s issues. So it is probably true that having more women in the room will ultimately help to advance policies that address those issues.

To make that point more concrete, currently there are 12 bills in the South Carolina legislature related to Covid-19 that we are tracking. And very few of those bills are actually friendly to public health. In addition, just this week, S.1, which is the six-week abortion ban bill, got further in the legislature than it ever has before. It’s probably going to pass.

How and why is that happening? It’s interesting. Some of it might be the result of people being upset about the recent election. But who can actually be in the room right now to testify against that bill? It’s not likely to be people who are pro public health, which includes a lot of women. It’s not going to the primary caregiver at home because their kids may be home from school. And we know a lot of those caregivers are women.

So it is interesting that we are seeing a lot of these negative policies right now, whether they’re about abortion, mask wearing, or vaccines. The authors of these bills are not women. The people moving these bills forward are not women. And the people testifying in favor of these bills are often not women. It is frustrating to watch.

[OnlineEducation.com] The advice that you gave earlier about taking data courses and programming courses is a solid one for women and men who are considering a career in public health. Are there specific resources you recommend to women entering the field?

[Dr. Gareau] Well, I’m biased because I’m on the board of the APHA, and if you are a student or early career professional, you can join APHA’s Student Assembly either for free if your institution is an agency member or for a low cost otherwise. The Student Assembly can provide all kinds of opportunities for networking, which can be a good head start on advancing your career in public health. Also, the APHA is such a broad organization that it can serve as a resource for helping you decide on an area of public health you might like to land on.

The other advice I would give is to look to local public health organizations. Each state has its state public health association. We have the South Carolina Public Health Association here, and that’s how I eventually made the leap to leadership within APHA. In fact, it’s probably why I am on the board today. My mentor told me that I should think about going to the state public health association meeting and I very quickly became involved in developing programming for the statewide conference, and that led to similar involvement with the APHA. So that would be the other suggestion because those state meetings are friendly and welcoming even for undergraduates. From there, you can get connected to the national work.

I am also really focused on the intersectional aspects of all of this. I was someone who couldn’t afford to take an unpaid internship when I was a student, and that is a disadvantage in a field like public health. It’s also another reason to make an effort to acquire marketable IT skills: if you can’t afford to take an unpaid internship, which is how a lot of people advance early in their careers, then you may be able to get a paid position that will allow you to network and advance your career that way. A lot of public health internships are unpaid, and many of them require you to be in DC, which is so expensive, so that can be a real barrier. I can end on that thought. It’s not just about all women in leadership positions, it’s about which women are able to advance into leadership positions.