Florence M Simán

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The interview is part of an investigation on Latino immigrant access to health care services. It was organized around a few major themes: the structure of the non-governmental organization El Pueblo, Inc., Latino immigrant access to health care services and health information in North Carolina, and the value of education and prevention work in reducing structural barriers faced by Latinos. As Director of Health Programs at El Pueblo, Inc., Florence Siman stresses the importance of understanding the needs of the Latino communities and her responsibility in addressing those specific needs through her various programs. Siman and her work at El Pueblo fills an essential role providing immeasurable support and resources to Latino immigrants struggling to overcome the obstacles barring them from equal access to health care in North Carolina.



Rachel Burns: Hello. This is Rachel Burns, interviewing Florence M. Siman on April 11, 2012. It is 9:30 am and we are at the Caribou Coffee on Franklin Street in Chapel Hill, North Carolina. Thank you so much for meeting with me. I’d first like to get a brief background about you and really any anything you'd like to note.
Florence Siman: Okay. I was born in El Salvador, lived there till I was 13. My family moved here in 1980 because all of the problems in El Salvador with the idea that we would be here perhaps for a couple of months or a couple of weeks. My father has a friend who lives in Chapel Hill, who is a professor, who is Salvadorian. And so, we came here temporarily, and I can't believe that I am still here 32 years later. My parents went back. My siblings went back and I am the only one in the family still left. I went to Chapel Hill High School and then to UNC. Then, took a year off and then went back to UNC and got my Masters in Public Health. And I have been working on Latino health issues since I graduated. I think I graduated in '91. So, I can't believe it's been 20 years.
RB: Where did you start working after your Masters in Public Health?
FS: It was actually a complicated thing because of my immigration status. It was hard initially for me to get a professional visa to be able to work here. I was here as student. I was here as a tourist with my parents. Then I became a student and I had an F1 visa. And then after that I applied for what’s called practical training, which is legal permission to stay in the US for a year after you finish a degree. And so, I was able to be here for a year. And then I had to apply for a professional visa called the H1-B visa, but you can only apply for the visa if you have a specific job that's requesting you for that visa. So, I actually had seen a job advertised that I was interested in Pittsboro. And so, well, actually the first job I had right after I graduated was a practical training thing and it was with the state. And then, after that I was able to get another project with the state for a year and I got an H1-B visa for that. And then after I finished that, then I applied for a position in Pittsboro, which was an agency called Child Care Networks. And it is a childcare research and referral agency and they were looking for somebody to develop a program to work with Latinos. When they offered me the position, I basically told them that I legally was not yet allowed to work in the States, but that I could if they were interested in sponsoring me. So, I applied for the H1-B visa and had it renewed. I was with them for 10 years. Yeah and eventually, I applied for my Green Card.
RB: Currently you're working in El Pueblo, Inc. A brief history of your involvement, getting initially involved in El Pueblo, and also a brief history of the organization itself.
FS: I actually became involved with El Pueblo maybe around '95 or '96. And it was basically, the guy who started the agency, John Herrera, was calling folks around town. He had moved to town with his wife at the time who's American. He is from Costa Rica. They had moved to North Carolina and were planning to start a family eventually and really felt like they really didn't have a sense of a community here yet and wanted to develop that. And so, he started making phone calls to all of the Latinos he met and asked those Latinos to give him names of other people he could call. And that’s how I was contacted. He had met somebody that gave him my name and we talked on the phone for a while and he was interested in organizing a Latin American festival. That was his initial and that is basically how El Pueblo started. And so, he asked if I was interested in being part of that group. I help a little bit that first year but not much. And that's when the first Fiesta took place. That was 18 years ago. I think after the event the group that helped organize it realized that there was a need to have more of an ongoing presence and more of a way of supporting the needs of Latinos in North Carolina and trying to portray the positive side that our community brings to North Carolina. I would say that maybe at the beginning of I think it was '96 the group decided that we should create an agency and incorporate El Pueblo. I think El Pueblo was incorporated in like the summer of '96. We decided that there were other needs and applied for funding from the Triangle Community Foundation and got our first grant, which was I think 2,500 dollars to do a leadership development program. And that year was mostly for folks who work in agencies that serve the needs of Latinos and trying to figure out how to address those needs. I think it took a while for the agency to take on the role of an advocacy organization and I am not really sure if that's the mission initially. I think the mission initially was mostly to try to figure out how to support what was happening and how to support agencies that were trying to do work with Latinos. I started as a board member and was a board member until 2003. In 2003, I found out that El Pueblo was interested in applying for funding from a private endowment in Raleigh called the John Rex Endowment. El Pueblo was developing a lay health advisor program, which I very passionate about. When I realized that El Pueblo was writing this application and presenting a proposal to John Rex Endowment to do this work, I realized that this is what I really wanted to work on. I resigned from the board, had nothing to do with the application process, and decided that I would apply for the position. I applied for the position and started working at El Pueblo in March 2004. It was interesting. I was exactly 10 years at Child Care Networks in Pittsboro, like to the day, which was crazy. I have been in El Pueblo for 8 years. I arrived at El Pueblo to do the work with Lideres de Salud, which the lay health advisor program. But eventually, I became the Director of Health Programs just because there was a need to do other health work.
RB: As director of the health program, I know on the website it talked about Our Rights Have Not Borders and Mujer Sana, some of your other programs included. So are you involved in all of your programs or specifically in a couple of them?
FS: As director, my responsibility is to secure funding. I am in charge of filling the report, supervising staff, which I think I do a really bad job because we have great staff, and so I feel like don't really have to do a lot. It's mostly I feel like I serve as a support. I sit with staff that I supervise to basically brainstorm about how to go about doing the program. But I don't necessarily… we have Derechos sin Fronteras, which is a youth reproductive health program. With that, I would say I spend maybe four hours a week with that program. So, it's a little bit supervision but it's also a little of brainstorming. With that program now, we have a team of five students that are from the School of Public Health that are working with us on the project. I meet with them pretty often and we review materials. It's like I am involved to some extent in each one of the programs I supervise, but I find like I am not the one who is actually implementing the program.
RB: Could you speak a bit more about the other programs? What their main objectives are? How they were established and why these certain programs are there, part of the program?
FS: Basically, the Lideres de Salud, the lay health advisor program, started in 2004 and the mission was to really improve the health of Latino children in Wake County. When we talk about Latino children, we realize that we need to of course include the families. You can't just be working with the children because they don't really have the decisions about health and nutrition. Through that program, we train community members as lay health advisors or promotores de salud. Every year for six years, we trained 30 promotores. We have a large network of promotores. I would say not many are still active cause this was a while back, but we have a bunch of folks that we actually trained on children's issues. They idea was to train them on prevention and also try to connect them to resources available in the community, making sure that people knew where to go for care. Also, there is a piece about advocacy, making sure that people felt comfortable advocating on their own behalf. So that they didn't necessarily need to depend on somebody else, but they understood what their rights were in relation to health care. They could go out and advocate for that. Out of that program, we conducted a formal evaluation. We had an external evaluator to conduct a formal evaluation. There were two issues that were brought up as the main issues that we should address. One was mental health and the other one was reproductive health. We did not address mental health specifically with the program because Duke and UNC have a partnership with a program called ALMA. They’re already doing that, so it felt like there was no need for us to replicate that. But there was really not enough work done on reproductive health issues. It is also my passion. At that time, I was communicating with folks from IPAS, which is a global health organization here in Chapel Hill. They do a lot of work in relation to abortion and abortion access. They were very interested in addressing the needs of Latinos in North Carolina and being very broad about the needs: not just looking at abortion, looking at reproductive health and access. We were able to get a little bit of funding from them to train some of our promotores on reproductive health issues, which was great. I combined the task force of different promotores and then people from the health department and from other agencies and we developed a curriculum. Mostly, I would say we adapted a lot of ( ), we looked at a lot of curricula that were developed in others parts of the US and Latin America. We took pieces together to create something that would be helpful to folks here. It talks about anatomy, human rights, sexual reproductive rights as part of human rights, making sure that it is seen through that framework. It looks at gender and identity. It looks at sexual diversity. It looks at family planning. It also looks at how to talk to children about sex and unplanned pregnancies. One of the things that I like about the work that we are doing is that we are trying really hard to stay very objective and not to tell people this is what you should think. It's more these are realities of things that happen in our community. We are not telling you that you should agree with this or not. We are just saying whether you're okay with abortion or not; it's not for us decide. It is for you to understand that these are things that happen in our community. Whether we want to accept it or not, they do happen. Same thing with homosexuality or access to birth control. Some people are completely against it; some people are not. Our role is not to say you really should believe this, but it is more that these are the issues and that these are the things that are happening in our community. As a promotora, you need to be aware that these things are out there and that abortion is legal in the US and that access to family planning is legal in the US. From that, we trained several of our promotoras on reproductive health. Interestingly enough, one of the youth from another one of our programs came up to me one day and said, "You know Florence, I love that fact that you're doing all work with promotoras about sex, but why don't you all do that with us?" He is somebody that later came out to me. We realized that yes, we knew that we had to do it and I told them, I said that “I really want us to do that but we really don't the funding.” We talked to the folks at IPAS and we co-wrote a grant with IPAS and we sent it to Z. Smith Reynolds and got funded to do work with youth. That's been really, really exciting and that's Derechos Sin Fronteras. Mujer Sana is a program that we no longer have. It was funded through Glenson Smith Klein. Interestingly enough, they called me on the phone and said we've heard lots about your work with breast cancer and Latinas. Do you have all the funding that you need? Of course, I said, “No, we don't have all of the funding that we need.” She said, “What would you want to do if you had extra funding?” I said, “You know one thing that we've realizing is a huge issue is that Latinas need not only information about breast cancer but once we provide them information on breast cancer, they want information on gynecological cancers. Through Koman, we can't do that.” They gave us funding to do that work, which was pretty exciting. We were also able to provide women with gas cards to be able to make it to their chemotherapy appointments, which was also really exciting because it’s also a huge barrier. The breast cancer program we've had since 2003. That came about… again, it's just realizing that that's a huge need. It's rally hard to understand how the healthcare system works in the US or doesn't work. It's been trying to figure what kinds of things the community needs and figuring out how to be responsive to that.
RB: Introducing controversial topics to the Latino population, has it been well receptive by the promotoras?
FS: Yeah, I was actually a little concerned when we were trying to put together the curriculum on reproductive health issues. I was worried about the family planning piece, when we are talking about birth control and condoms, talking about unplanned pregnancies and that abortion is one of the options. Then, talking about homosexuality and bisexuality and transgender, transsexual. But I think the way we presented it was very helpful and being able to say, “We are not trying to brain wash you. We are just trying to make sure that you understand that these things are happening and that you might see things differently. We don't want to tell you that have to think a certain way.” In a way, trying to open people's minds. We are trying to open people's minds, but it is not in a way of saying this is what you have to think, but trying to give them the perspective that really we are nobody to be able to judge somebody else's decisions or somebody else's way of life. It’s been interesting because I feel like people have been pretty receptive. I guess those other people who have participated in the program, so I am sure there are people who have decided not to participate because they feel like the issues that we are addressing are too out there. I actually had somebody who came up to me, “So you mean to tell me that you are telling me that our youth that being gay is okay?” And I said, "Yeah, exactly what we are saying." We are not telling them, yes to the adults this is what you have to think or to the youth this is what you have to think, but yeah, of course, that is the message that we are sending out because that is how we feel.
RB: Do the promotores go to different communities or have meetings in neighborhood? How do they conduct their work?
FS: It really depends. Most of the work that the promotores have done has been informal, so it has been through their own networks. It's been talking to their friends at work, talking to their friends in their communities, talking to family members. I feel like most of them that's the bulk of the work that they do, but we also organize health fairs. El Pueblo has a huge event that happens in September every year, El Fiesta del Pueblo. The promotores usually have a booth there and share information there. Also, some of the promotores do work through their churches. They would sit either outside after a service and provide information about health. We have done PSAs; we have done articles in the radio. They have been on TV shows. I feel like we have tried to figure out ways how the promotores can get out there. Right now, we don't have funding for the Liders de Salud program. We have not have funding for that for two years, but we still continue meeting with them once a month because I feel like they have been the core of the health programs that we do. They are the ones that kind of tell us what the needs are. I have a sense of what the needs are, but I am not out there doing work in my neighborhood on a daily basis and the promotores are. I feel like they are the ones providing us with the information about our path, which way we should go, where we should request funding.
RB: Do you think a lot of these health programs are helping to solve problems with accessibility? Is there more you all could do? Are sometimes just structural barriers that you can't get over?
FS: I would say the biggest issue that we face right now and that the promotores face and the families they work with is immigration issues. People not having access to a driver's license is a huge issue. Public transportation of North Carolina is not good. I would say perhaps in Chapel Hill, maybe it is okay. But outside of the Triangle, it is really not possible and even in the Triangle. I mean it is really hard to get to work on a regular basis if you rely on public transportation unless you work at the university. That's one of the biggest barriers. It's hard for the promotores to get to meetings. It's hard for the community members to be able to access health care because they can't drive places or they are driving places and they're really scared because they don't have a license. So, I would say that is one of the biggest issues. The other issue that we are facing right now is the economy. I realized that many of the promotores that had more time. It is two issues. Some of the promotores that weren't working have gone to work because some of their spouses are either unemployed or underemployed. In so, one of them is having to go back to work. They other issue is that gas is pretty expensive. For the promotores in the past, the promotores were willing to do a lot of work for free. But now that we are not even providing incentives for the promotores, for them to take the time to drive around and then spend gas money to try to get to meetings is pretty hard. I think that is also pretty hard for folks in the communities, being able to get places. I mean there are so many barriers. I think just access to health care here in the US is just pretty complicated because I would say that most Latinos or many Latinos here in North Carolina work in jobs where they are not provided health insurance. It is a really a luxury when it should not be, but that is the reality. For many it is a luxury that they can't really afford. It's continuing that process of you go to the emergency room when you need to, even though that is part of what we are trying to talk to folks about. The emergency room is extremely expensive and it is better for you if you can go to a specific provider and to urgent care. Even though it is expensive, it is not as expensive as the emergency room. Then, I would say access to just information about health and where to go for specific services. I think there is a lot of confusion at times about that.
RB: Coming from Pittsboro, an area where I would assume there are a lot less resources than resource-rich Chapel Hill for example or even Raleigh, do you think that these rural areas have enough support? What should an organization in a larger city do to help aid these places that are lacking the resources to provide information and clinical resources as well?
FS: Our agency is statewide, but we really struggle with that. We're right now nine staff members. We have 100 North Carolina counties. I mean it is impossible to be in all of the counties. Our public safety program for example has worked through regional coordinators. They have regional coordinators in five different parts of the state. They send information out to those coordinators and those coordinators are responsible for a certain number of counties to get the word out. I think that's one way can get the word out and messages out. I think using media is another way. But then the other thing that we have tried doing as an agency is trying to support agencies, trying to build to capacity of agencies to work with Latinos and to figure out how to address the needs of Latinos. So it's kind of providing technical assistance. It's raising awareness about the need and then also trying to provide that technical assistance for folks who are interested in reaching out to Latinos but they don't really know how. We do that with our health programs, specifically with our Koman. Right now, we have two Koman programs. One works in 16 counties and it is specifically to provide technical assistance to folks in other counties who don't really know how to serve the community. The other is in Chatham. The reason why we are in Chatham is because I had worked in Chatham for 10 years. I have lots of connections in Chatham. The program that was in Chatham previously was run by UNC and the person who supervised the program retired. When she retired, UNC said we can no longer run this program. I contacted folks in Chatham that I know, agencies in Chatham, to see if one of the agencies could take this program on and request funding to do this work. They said, “We really don't have the capacity right now, is there any way that El Pueblo could take it on?” In so, I wrote the grant and we're taking on the program to do work in Chatham. It hardly provides funding for the agency but I feel like it is a program that was necessary. I feel well, the county didn't have the capacity and we have the connections. We have the support of the folks in the county to be able to do the work there.
RB: It seems a lot of the programs based in El Pueblo are focused on education and health education. Do you see a greater value in putting your resources into health education instead of for example simply medical care like a free clinic?
FS: I feel like the role of our agency is more like on the advocacy piece. I feel like yes, it is important to put funding into clinical care, but I think that it is also very important to provide funding to the prevention piece. I feel like often people don't talk about prevention as much. I feel like there are a lot of things that each one of us can take responsibility for. I think as an agency is looking at the social determinants of health and trying to figure how to make sure our community is not blamed for certain situations that we are dealing with, for example obesity. I feel like people have a tendency to say, “Well, Latinos they come to the States; they change their diet; they become lazy; they don't walk around.” Well, yeah, maybe, part of that is true; that is the reality. We live in this culture. We have two jobs and we have to run around like crazy and we don't have time to cook like we used to have time. Public transportation here doesn't work in so we don't walk places to get to the bus. We drive places. I think that is part of it. But I think there is the other side of understanding that yes, we do have personal responsibility. As a society, we have reasonability of the places where people live. So, do people feel safe walking around there neighborhoods at night? No. Maybe they don't. Maybe during the day, they don't feel safe. Maybe there are no sidewalks for them to be able to walk around. Maybe there are no greenways. Maybe in the neighborhoods where they live there are no stores. The only thing they have is a convenience store or a Hardy's or a McDonalds, places for fast food. If you don't have transportation, it is so much easier to get to those places. I feel like it is important to do work on both sides. I feel like out organization is not a clinical organization. It is an advocacy organization. Our piece is more on prevention.
RB: Has there been a general awareness from citizens in North Carolina, the general population, about El Pueblo and your work? Is there an interest for funding reasons and also for just getting involved?
FS: I really feel like it fluctuates. I feel like there was a time a few years ago that I felt like applying for funding as a Latino agency was great because I feel like people were really excited that Latinos were the new community here. But I feel like that has changed. I feel like the excitement that was there perhaps five or seven years ago is no longer there or as strong. But I guess it really depends on the funder. I mean there are some agencies that are still really interested in strengthening the Latino community. I do feel like there is a much stronger anti-immigrant sentiment than there has ever been. I think as hard as an agency for some of us to continue to be excited and inspired when you feel like there is so much hate out there. Our community is facing so many different barriers. It's really hard to motivate our youth sometimes to stay engaged and to stay in school when they feel they don't really have a future, they don't have any options. They can't work in the US. They can't go to college. Why make an effort? So that can be discouraging. But there are still some foundations and some folks in the community that are very excited about supporting our work. I think the general public and I get the feeling that people are interested well some people are interested. There is still a lot of miss information. We get phone calls from folks who will call and say, “You know I'm a teacher at such and such school and I working with this youth who is undocumented and she is extremely bright. We want to figure how we get her legal. Can you help us?” It's being able to explain that it's not easy and it's very complicated. It's understanding how a lot of those conversations that we have people are horrified at that reality. People have no idea what the reality is. In so, our response usually is that you need to contact your member of Congress. You need to talk to your representatives and make sure they hear your opinion ‘cause you're a US citizen who lives in a rural county. You need to take a stand. I feel like there is a lot of misinformation and I feel like a lot of people don't make the effort to try really understand the realities and how complex it is. We hear a lot, "Well, why don't they just become legal?" Without really understanding that's not an option. That's really complicated. Part of our responsibility is making sure that that gets out there. That people really understand that it's not that people don't want to come here legally; it's that there are no options. That it's very complicated.
RB: The effect of the Affordable Care Act, do you think that is going to have a positive or negative or be sufficient enough to support the Latino population?
SF: For right now, it's not going to have a huge effect directly because if you're undocumented then you're really not covered at all. I think the only way that it would have an effect is through promotores because the Affordable Care Act is going to be supporting the work of community outreach workers. I feel like in that respect that will have an impact on our community. It's mostly again prevention, not necessarily access.
RB: Have you seen in your work a culture of natural or traditional medicine among immigrants using it to supplement their healthcare or lack of healthcare here?
FS: Wait, ask me that again.
RB: Have you seen a culture of natural or traditional medicine among immigrants?
FS: We've seen or I have heard from the promotores that we do have what you call either curanderos or salvadores, traditional folk healers. I would say folks rely on that but I wouldn't necessarily say that it's shifted because of recently but I think it has been like that throughout. So in relation to that, I was thinking that some of the promotores have said that what they've realized that people will go to a traditional healer first and if it doesn't get better, they'll go to a traditional healthcare or the other way around. People actually do rely on their networks from back home to have them send specific things. In so, you might be talking to your mom in El Salvador, in Mexico, telling her that you are having this and this symptom. You might be diagnosed by your mom or a family member back home or your doctor back home and they're sending you medications. So we have seen that happening a lot. People relying on some of the tiendas to purchase drugs, seeing that and some of the tiendas also sell some of the traditional herbs that we use.
RB: My last question, next steps in expanding El Pueblo or just with your work with El Pueblo.
FS: Well, I am actually really excited. We just hired our executive director and two days ago was her first day. So Monday was her first day. I am really excited. Our agency has been without an executive director for two years, which was okay because I think we have pretty amazing staff. But it's great to have somebody to help, especially with the fundraising piece. I feel that just like every other nonprofit we have struggled financially like everybody else. It feels really nice to know that we have somebody who has a lot of experience doing fundraising and also working in collaboration with other agencies. I think that is something that our agency is really interested in doing now. I am really excited that we are having elections this year. El Pueblo will be doing "Get Out the Vote" again, as usual. Understanding that the Latino vote is very importance and trying to encourage and mobilize folks in our community. In relation to health, right now my funding is pretty iffy. I have funding for part of my salary and not for my full salary past June. I'm really interested in securing funding for my position even if I'm no longer there for my position because I feel like El Pueblo needs to continue having a Director of Health who focuses on grant writing to be able to support all of the health programs so that we can be able to be responsive to the needs of the community. That's one thing I didn't say but I am really proud that with the health programs we've tried really hard not to go after funding because the funding is there. But to make sure that we are responding to the needs of the folks we are working with.
RB: Well, thank you so much. I appreciate you coming and taking the time to meet me.
FS: Thank you.