“What's Love Got to Do with It?”

I left a little snack for you in the fridge, said Mildred when I called to tell her in June 2005 that we would be arriving in Ahoskie, North Carolina, with our moving van from New Mexico in the late afternoon. After unloading a few necessary boxes and becoming adequately drenched in the new experience of humidity and intensive sweat, I headed to the refrigerator in the quaint little kitchen and was perplexed by the four cans of Pepsi and a six-pack of bright orange crackers. Oh, how sweet, Mrs. Peele left you Pepsi and Nabs! one of our volunteer movers exclaimed. Admittedly, that cold, sweet drink and those salty peanut butter cheese crackers hit the spot that day and introduced me to an Eastern North Carolina food tradition. Although I don't often drink a soda or eat a cheese cracker these days, I know these signature snacks are a part of the fabric of life in my adopted home for the last 13 years.

As the CEO of a federally qualified health center (FQHC) with five rural Eastern North Carolina counties within our designated service area, I am well aware of the incredibly negative health outcomes impacting our families, friends, and neighbors. Taylor Sisk, in her June 2018 article for North Carolina Health News summarizing the 2018 County Rankings published by the Robert Wood Johnson Foundation in partnership with the University of Wisconsin Population, wrote: Health outcomes in the County Health Rankings are measured by how long people live and how healthy they feel. Length of life is measured by premature death—deaths that occur before individuals reach their statistical life expectancy. Quality of life is measured by the percentage of days people report poor or fair health, the percentage who report physically and mentally unhealthy days within the past 30 days and the percentage of low-birth-weight babies. The disparity between rural and urban counties in these measures and others is often stark [1] …

The County Health Rankings authors write that poverty limits opportunities and increases the likelihood of poor health. Children living in poverty are less likely to have access to quality schools and have fewer chances to prepare for living-wage jobs leading to upward economic mobility and good health [1].

Sisk, thankfully, does not leave it there and emphasizes in her article that seldom are the strengths and resiliency of the rural community talked about.

Place-based inequalities are important determinants of health specific to urban and rural high-poverty communities [2]. “There are a lot of unique features in rural areas that could lead to higher levels of obesity,” write Piontak and Schulman. “Food insecurity, poverty, the inability to recover from economic recession, or a lack of access to grocers could all potentially affect obesity rates [2].” The researchers also found that a student who attends a high-poverty school is 1.5 times more likely to be obese than a student attending a low-poverty school [2].

In 2015, a number of community partners came together in Hertford County to form a new program aimed at the heart of addressing healthy eating and active living (HE/AL) called Farm to School to Healthcare (F2S2H) [3]. The aim of this project is to harness community assets in service of improving overall wellness with the long-term goal of reducing health disparities.

For years, our partners have expressed concern, based on anecdotal evidence, that residents of Hertford County were unable to access fresh produce. Through community surveying conducted in 2015 and summer and fall of 2016, our team was able to quantify this problem. With the implementation of a social determinants of health survey we found that only 44% of respondents were able to purchase fresh produce as often as they would like. In addition, 65% of respondents were unable to walk to purchase fresh produce, which is a significant barrier due to the large number of residents without a personal vehicle and with limited access to public transportation [4]. Findings from the survey were consistent with the latest data from the County Health Rankings, which indicated that Hertford County has the eighth worst Food Environment Index in North Carolina [3]. We also know based on state data that Hertford County has the fifth highest food insecurity rate in the state [5]. Although there is a small farmers market in Hertford County the options for sustainably grown produce are noticeably absent and the isolated nature of residents without transportation indicates the need for additional market locations. In 2018, Hertford County ranked 94th out of 100 counties in North Carolina for health behaviors [3]. Forty-one percent of adults are identified as obese, compared to the state average of 30% [3]. Contributing factors include lack of physical activity, with 32% of adults reporting no leisure time physical activity, which is significantly higher than the state average (24%) [3]. Only 61% of adults have adequate access to locations for physical activity compared to the state average of 76% [3].

There are deep connections and generational traditions of food, place, spirit, and activities in Eastern North Carolina that until just the last 50 years were not considered in general to be part of a harmful lifestyle. Families, friends, and neighbors coming together on a Sunday after church for an outdoor picnic connected us generationally. We served up large platters of country ham, fried catfish, and chicken accompanied by butter beans, fatback-soaked beans, collards, and cabbage all lovingly grown in the garden. Add to that fluffy homemade biscuits with jams put up earlier in the season and sweet corn on the cob and top it all off with seven-layer chocolate cake, banana pudding, and molasses cookies all washed down with large Mason jar glasses of ice-cold sweet tea.

When you are told that nearly all of the traditions and the joys that are passed down from your loving family are not healthy and will eventually be your downfall, how is your community to respond?

We respond with the same love that is shown at those Sunday dinner tables—by recognizing what makes a community strong: the spirit of its people. How do you get a child who, when asked to name an orange fruit shouts, “HOT FRIES!” to eagerly try fresh sugar snap peas? How do you convince a classroom full of high school students, of which only three had ever been to a farmers market, to volunteer after school to not only attend a market, but run it? By giving them a seat at the table, letting them actively participate in the process and ultimately the solution.

The F2S2H initiative strives to address issues reflected in our preliminary data from the Youth Risk Behavior Survey implemented within Hertford County among 10th-graders, which found many concerning statistics related to HE/AL. For example, 74% of respondents ate fruit less than once a day in the last week, with nearly 20% not eating fruit at all in the last week [3]. Conversely, 18% had a soda at least once each day over the last week. F2S2H has responded by working to develop and expand school gardens, increase access to local, sustainably grown produce, and teach youth and community members gardening skills. Only 25% engaged in physical activity for at least 60 minutes each day over the last week. Forty-eight percent reported using smartphones, tablets, or computers more than four hours on an average school day for activities not related to school work. Thirty-five percent watch TV four or more hours on the average school day [3]. To address these findings, F2S2H is working to create an environment that supports community partnerships, youth empowerment, and HE/AL activities.

Through the F2S2H initiative, Hertford County Public School system students and teachers are engaged to manage school gardens on their campuses. One may question, “What's special about a school garden?” but our team didn't want to put this problem off on our overworked school teachers. With that in mind, we searched high and low for community partners who could wrap around the schools and help them elevate their gardens beyond the classroom. Students are treated as equal partners in our work; the team embraces their creative energy and ideas for how to grow the program. They run their own farmers markets, learn cooking skills, and implement cutting-edge garden technology such as arduinos that can measure soil moisture.

Over the last three years, the F2S2H initiative has expanded to five schools throughout the county, each with its own unique garden personality. The schools are given the freedom to integrate the gardens how they see fit and the diverse skills of partner agencies are woven throughout. Hertford County Early College High School has launched a food justice unit where students learn about our food system and explore methods of improving it. They learn about the stories of backyard gardens in their communities and they go home to ask their parents and grandparents about what their relationship with food was like when they were young.

The main event of the year reflects some of the best traditions of our community; we gather for a large farm-to-table dinner at the end of the summer, celebrating one another and building energy for the new school year. The entire community is welcomed to join, and in true neighborly fashion, we don't ask anyone to pay a dime. They pay us with their love and support that is so evident every time our students host a market, each time we call on them to help build a new garden, and with each family that decides to “just plant a few seeds and see what happens.” We won't tell a grandmother she is wrong for making a special dessert when her family is mourning; we won't label a patient “non-compliant” because they didn't run out and load up on fresh produce after their diabetes diagnosis; and we won't lecture a father about why he doesn't take his kids for a walk after school. Instead, we will welcome you into our kitchen to learn how to tweak your family favorites so they are a little healthier; we will give doctors Produce Prescription Vouchers so they can make sure their patients can afford to shop at our markets; and we will do what it takes to make our communities more walkable, whether it be on our new walking trail or by working with youth on Photovoice projects highlighting areas of concern, but more importantly ideas for building on what we have. We do this because we recognize obesity and related chronic conditions are largely problems of systems and circumstances related to place and poverty. Yes, we have personal choices, but when the choice feels out of reach for most of our neighbors, we know that there are things that we as a community must address before we can expect our families to make changes. We believe that this is how to bring about change in healthy eating and active living in our community: by embracing what makes us great, the love our people share for one another, and that time-tested tradition of taking care of each other. So, we move slowly, we dream big, and we welcome as many people to the table as we can.

National Geographic Fellow Dan Buettner, who coined the term Blue Zones to refer to regions of the world where people live longer than average, has identified the world's happiest and healthiest people. He reports that something is wrong with the way life is organized in most of our nation, arguing that there is something about the foods we consume, the frantic pace of life we keep, the relationships we make, and the communities we create that keeps us from being as happy and as healthy as we can be [6]. What I have recognized since relocating to Eastern North Carolina 13 years ago is that our rural communities have the ingredients—deep generational connections and mobilized partners spanning education, health care, faith-based organizations, non-profit funders, and government entities committed to the upstream and the long game—that are needed for meaningful HE/AL change. Love and connection are some of the components that transform the human heart, spiritually, socially, and physically contributing to deep connection. By focusing on general well-being components that are already in place and emphasizing the environment of good health rather than lecturing and instituting unhelpful programs, the results have a greater chance of long-lasting positive impact. With each small success over the last three years, the F2S2H partners are encouraged. Frequently they remind each other of the proverb: “If you want to go fast, go alone. If you want to go far, go together.”

• ©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.