Fabiola Santiago

Fabiola Santiago
Research Associate

Fabiola Santiago first came to Human Impact Partners as the 2013-2014 Health and Equity Fellow before transitioning as a research associate. Her passion for social justice and public health was ignited through the various experiences she navigated as a formerly undocumented immigrant and as an indigenous woman from Oaxaca, Mexico. These experiences exposed her to institutionalized racism and several forms of oppression, and witnessing similar experiences in low-income communities, communities of color, and other marginalized communities made it clear that in order to improve health, changes in social determinants of health must be addressed. Prior to joining HIP she was a research analyst at Special Service for Groups Research and Evaluation Unit, where she used community based participatory research approaches and empowerment evaluation to bolster community engagement and capacity building in health related projects, plans, and interventions. She firmly believes that community input is a necessary part of public policy and uses her fluent Spanish skills to ensure the highest level of engagement from Spanish speakers in projects. Fabiola received her Master’s degree in Public Health and Bachelor’s degree in Sociology from University of California, Los Angeles.

Together we are Stronger: Intersectionality of Immigration and Incarceration

Last week the Haas Institute for a Fair and Inclusive Society launched We Too Belong: A Resource Guide of Inclusive Practices in Immigration and Incarceration Law and Policy at a half-day event that brought together the contributors to share their stories, their work, and engage in meaningful dialogue.

Immigration is often thought of as a Latinx issue, and incarceration thought of as a Black/African-American issue. However, the event centered on the intersectionality of these issues and highlighted that the immigration and criminal (in)justice systems are highly racialized. For those of us who have been impacted and involved in one movement or another, this is nothing too new — we’ve experienced the entanglement.

Experiencing the entanglement of immigration and incarceration is one thing, but this event generated the necessary uncomfortable conversations about how the systems have us working in silos, pointing fingers at one another, and fighting for resources. These approaches perpetuate oppression, fuel violence, hate, and pin us against each other. Working together makes us stronger, and is a key part of the process for liberation. I believe that these conversations need to be had among groups and organizations working on social justice and public health issues.

Particularly, I want to share a few nuggets of wisdom that panelists at the event announced and that I think anyone working for a more just and equitable society could reflect on:

  • Build transformational relationships instead of just transactional ones. We need to show up as much as possible for our partners; our work is not over after we’ve completed a project.
  • Elevate lived experiences, highlight non-traditional and inspiring stories, and create unified narratives. This is quite a task to accomplish especially while also recognizing that communities are not homogenous, even within the immigrant community, for example.
  • Expand the level of human concern in the policy work we do. This means making sure we use inclusive language and check ourselves.
  • Work towards what we want, not just towards what we don’t want or what we’re fighting against. Let’s use our energies effectively!

The overarching message I took was that while we work to dismantle oppressive systems, we must remember that at the core of it all are individual humans. Yes, poverty and racism are hurting and killing us, but we should equally acknowledge that we are also strong, resilient, and powerful.

The communities most impacted by policies are the ones with the solutions, we are not saving anyone—this was very clear based on the faces, stories, and histories panelists shared. Our task in public health (or whatever sector we work in) is to elevate that strength. By elevating community strength, we elevate our collective strength.

After each presenter shared their work and their story, the event attendees repeated these beautiful phrases, that reminded us how intertwined our work together is. I invite us all to contemplate these words as we continue our work together: Thank you. Thank you for your story. Thank you for your work. My freedom is bound to yours.

How Payday Loan Reforms can Improve Health for the Most Vulnerable Minnesotans

“Every two weeks I was just paying interest. And I think I got frustrated with it because knowing that the interest you’re paying really isn’t even close to what you took, and by the time you know it, you paid more than what you took from them. . . It eats you up, really, and it’s very stressful to deal with that, not knowing where you’re going to live next, or how you’re going to come up with your rent, yeah, it doesn’t really help much.” — Mercy, borrower

Human Impact Partners and ISAIAH are excited to release the report, Drowning in Debt: A Health Impact Assessment of How Payday Loan Reforms Improve the Health of Minnesota’s Most Vulnerable. After examining literature and data from many sources, the study found that the payday lending debt trap harms the health and wellbeing of Minnesota’s payday borrowers, their families, and their communities. And there is no available evidence that access to payday loans has beneficial impacts on borrower health. Ultimately, eliminating the payday lending industry in the state – or else implementing significant reforms – provides the best opportunity to ensure that health risks to borrowers, their families, and communities are minimized.

Here are the facts: Payday loans are marketed as short-term, quick, and easy loans, but the industry thrives on repeat borrowing—90% of their revenue comes from borrowers who cannot pay off their loans when due. Furthermore, between 1999 and 2014, the wealth drain from payday loan fees and interest amounted to more than $110 million from communities in Minnesota—and more than $13 million in 2012 alone.

The evidence also points to that the payday loan business model targets vulnerable populations. Storefronts are more likely to locate in communities with higher proportions of low-income residents, people with lower levels of education, immigrants, renters, and particularly, African Americans. The industry perpetuates the inequities these communities experience. For example, African Americans in Minnesota lag in homeownership, an indicator of wealth, with only 21% owning homes compared to 75% of whites who own homes. African Americans also have a higher poverty rate than whites in Minnesota, 38% versus 11%, respectively.

Along with this wealth drain, targeting of vulnerable communities, and worsening of economic inequities, payday loans were found to directly affect the health of borrowers and their families. Borrowers experience high levels of stress from worrying about being in debt and repaying loans. Chronic stress, particularly financial stress, has profoundly negative effects on health, including cancer, heart disease, stroke, diabetes, hypertension, ulcers, and compromised immune function.

Most counties with a payday loan store rank in the bottom half of the state for health outcomes, and payday loans exacerbate existing health inequities between white Minnesotans and people of color who also have higher rates of infant mortality, obesity, diabetes, heart disease, and premature mortality.

Minnesota is the worst state in the country in terms of the wealth gap between whites and people of color, and payday lending is only one factor that contributes to that reality. These outcomes are the result of long-standing social and economic policies that converged to drain wealth from low-income communities and communities of color, and have resulted in an economy where chronic underemployment, stagnant wages, race and gender discrimination, and other experiences are the norm for many lower wage workers. All of this comes at the expense of health and wellbeing of communities throughout Minnesota and the nation.

In our research, we talked with Gynnie Robnett of the Americans for Financial Reform, who refutes lender claims, and said:

“[Lenders] say, ‘We are providing a service to people who need money. Without these loans where would people go?’ We respond – if someone is drowning you don’t throw them a deflated life raft. People are struggling in this country; they are not making enough money. The loans are marketed as a quick fix, one-time thing and they are not used this way. The loans are used for everyday expenses and they trap people in long-term debt. Instead of relieving a crisis you are creating a new crisis.”

Our report supports the findings of many researchers that regulations are needed to prevent the payday loan industry from taking advantage of the most vulnerable Minnesotans. Stronger regulations on payday loans would help protect more than 50,000 Minnesotans and their families from these impacts.

However, the absolute greatest benefit to health and equity would be the elimination of the payday lending industry altogether. The opportunity has arrived for lawmakers to curb predatory lending practices and help improve the health of Minnesota’s most vulnerable communities.

Follow the conversation on Twitter at #DrowningInDebtMN.

Wage Theft: A Victory for NY Nail Salon Workers, but Others Also Need Protection

Last month The New York Times ran a two-part front-page series shinning light on the dark truth about the oppressed and dangerous lives of nail salon workers.

One story – Perfect Nails, Poisoned Workers – uncovered the health hazards of working in the nail salon industry. The daily handling of toxic chemicals in nail products leads to respiratory problems, skin irritation, liver and kidney damage, miscarriages, birth defects, and other developmental problems in children.

The other story – The Price of Nice Nails – exposed the low wages, poor working and living conditions, and social factors that make nail salon workers especially susceptible to exploitation. Few workers are paid the state’s legally required minimum wage. Tip stealing is common and overtime pay is non-existent. Workers often have to pay employers to learn a new skill and must either pay for or provide their own working supplies. All these are forms of what we’ve come to call wage theft.

Human Impact Partners’ recent Health Impact Assessment on wage theft in Los Angeles, similarly, found that wage violations affect workers’ housing, food security, childcare, ability to meet basic needs, and their opportunity to improve their lives. Many workers are forced to live and work in squalid, crowded conditions.

One barrier that makes low-wage workers more susceptible to violations is the inability or limited ability to speak English. One salon worker interviewed by the Times said that by learning English, she would increase her chances of landing better work, but chronic hand pain – common among nail workers – and exhaustion from long hours deterred her. This was also the case with workers in our HIA.

Another hidden nuance of wage theft is stratification and discrimination within low-wage industries. The Times series and our report found that there is a hierarchy of work and wages based on country of origin and language spoken among all low-wage workers. Newly arrived and undocumented immigrants often start with the lowest pay and harder jobs, which further divides workers and feeds competitiveness.

After the release of these stories, New York’s Governor, Andrew Cuomo, announced an emergency measure to protect nail salon workers. “We will not stand idly by,” he said, “as workers are deprived of their hard-earned wages and robbed of their most basic rights.”

The governor’s emergency measures include use of protective gear for workers and improved ventilation of facilities, posting of worker rights in multiple languages at nail salons, creation of an enforcement task force, and education campaigns through community groups. Salons must now be bonded to ensure that workers can eventually be paid if salon owners are found to commit wage theft.

Cuomo should be applauded for his response to the plight of nail salon workers in New York. But the issues highlighted in the Times’ nail series are common across many low-wage industries, and found from coast to coast. We would argue, as do the NYT authors, that farm workers, nannies, car wash workers, day laborers, dishwashers, busboys, construction workers, garment workers, janitors and others, experience similar work conditions and suffer from lax regulation of labor laws.

To address the social and health effects of wage theft in the State of California, we submitted a letter of support for bill SB 588, which would enforce current state wage theft laws and help workers collect stolen wages, and highlighted findings from our HIA. We were encouraged to see the letter reprinted almost entirely in the Senate Judiciary Committee’s bill analysis. Additionally, during lobby visits, legislators showed support for the HIA findings and the need for a health lens on economic issues more broadly.

The nail salon workers stories and wage theft experiences in Los Angeles, California, and across the nation demonstrate that worker protections should be extended more widely to low-wage industries more broadly. Doing so would protect the health and well-being of workers who are in vulnerable occupations, and would ensure they have an opportunity to succeed.

Tags: wage theft, NY nail salon workers, lo

Black Lives Matter: Intersections of Racism, Discrimination, and Health

I was in Thailand when the Ferguson case erupted. Traveling was a long-held dream come true – up until two years ago I was undocumented and couldn’t risk leaving the country. But even on this two-month trip to Southeast Asia, I could not avoid racism.

  • In Vietnam, I overheard a white man talking about his entrepreneurial plans, one being “Hire illegal Mexicans. They work hard and will do anything for very cheap.”
  • People seemed confused when I said I’m from the U.S., as if my appearance didn’t fit their idea of “American.” They’d often respond, “What about your parents?”
  • When telling other travelers I was born in Mexico, but have lived in the U.S. most of my life, I was asked several times if I was an illegal Mexican who jumped the border.

When Darren Wilson was not indicted, my friends and colleagues in the U.S. shared my outrage. But some of my fellow Americans at the camp where I was staying betrayed attitudes that showed how far we still have to go.

A traveler from Missouri said, “I don’t think the officer should’ve been indicted anyway – even the witnesses are changing their stories. The officer was in his right to defend himself. I think blacks are making such a big deal about this. They have the same opportunities as everyone else, in fact, they have better opportunities than me because they get money to go to school and I didn’t.”

I cringed when I heard this. I responded with examples of how blacks and other people of color in the U.S. actually do not have it easier. Though my examples came from personal experiences, knowledge, and research, they weren’t accepted as valid. Someone else jumped in to remark that black communities have these problems because it’s their culture, it’s in their value system, and it’s in their family structure.

This ignorant pathologizing of a people is damaging, especially in terms of mental and socio-emotional health. Black Americans fare worse on measures of health and quality of life compared to their white counterparts.

Starting from birth, black infants are more than twice as likely to die within the first year of life as white infants. Blacks also fare worse in low birth weight, pregnancy-related complications, and maternal mortality. Socioeconomic factors account only for some of these disparities.

After a black baby makes it through its first year of life, the odds are still against him or her. Nationwide, the graduation rate for black males is less than 50%. Blacks are incarcerated at nearly six times the rate of whites. African-Americans have particularly fared poorly in the War on Drugs: even though 5 times as many whites use drugs as African-Americans, African-Americans are sent to prison for drug offenses at 10 times the rate of whites.

If we truly believe that black lives matter, we must take responsibility to end not only police violence, but the wide range of policies and programs that are literally killing people.

Advice for New HIA Practitioners Interested in Equity

Why do some workers get paid sick leave, while 85% of food preparers have to choose between coming to work sick or losing a day’s wages? Why do fewer than 1 in 10 African Americans live in a census tract that has a supermarket, compared to almost one-third of whites? Why do we send drug offenders to jail when it’s cheaper and more effective to send them to treatment? How do these inequities affect health for all of us?

As HIP and others conduct innovative research that highlights the health issues inherent in all policy decisions, we are seeing an emergence of new public health professionals who are interested in Health Impact Assessment (HIA) and Health in All Policies (HiAP) research as tools to advance health and equity. In the first two years of HIP’s Health and Equity Fellowship, we have had 90 applicants from across the country, and with a diverse range of personal and professional backgrounds.

We asked Fabiola Santiago, who recently completed our first Health & Equity Fellowship: What advice do you have for emerging public health and HIA practitioners who are interested in health & equity research?


HIP’s Health and Equity Fellow is responsible for initiating and leading a new and innovative HIA or HiAP project that aims to advance the consideration of health and equity in decision-making. For my primary project, I led an HIA focused on proposed legislation to address wage theft, the nonpayment or underpayment of wages rightfully owed to employees.

In working on the wage theft HIA, I found that health and equity are still relatively new concepts for many organizations. Throughout this experience, I was simultaneously learning and teaching these concepts and the HIA steps. Patience is key. As someone with a strong background in social justice issues and an ardent inclination towards public health, the link between social determinants of health and health outcomes is evident to me, but it’s not necessarily explicit in research. Extra research is often needed to form predictions in areas where a health lens is not available. Budget additional time for each HIA step, and still expect delays.

During my fellowship, I also worked on a Health in All Policies project – the Local Control Funding Formula. This project involved a broad set of partnerships. I learned that each organization and individual may have a different agenda, some will be more equity focused, others more on health, and still others on other issues. Being mindful of these differences, yet staying focused on the overall goal can reduce confusion, but innovative ideas can emerge from the conversations. Communicating findings will generate more partnerships and garner more support in issue areas. Not everyone may use the same language, but the goals may be similar. Paying attention to these nuances has the potential to create new relationships.

For all the projects I worked on, I found it important to be flexible yet firm. As you embark on your project and especially while working with people and organizations you’re close to, it’s important to be flexible to their needs. But it’s also important to make sure that the project does not fall too far behind. Respect their feedback, incorporate their suggestions, but remember to value your professional expertise as well. As an emerging professional, it can be hard to make executive decisions, but it’s important to your development as a leader.

The purpose of the HIA is to first and foremost increase the consideration of health and equity in decision-making. However, if the HIA does not succeed in influencing decision makers, it does not mean it failed. Hearing, “Thanks so much for your work. I can’t believe we haven’t looked at how wage theft impacts health” is a sign that the overall purpose of the HIA is heading in the right direction. Additionally, when I conducted focus groups, seeing how candid participants were, and creating a space for them to vent was also a sign of success because it illustrated how much their working conditions impacted their daily lives.

Social determinants of health and community are key. Addressing health problems from their root causes will inevitably take longer, but in the long run will have a much greater effect. Changing the social determinants that influence people’s health has the potential to prevent and alleviate the most pressing health problems. Additionally, the field of public health must lead in elevating community voices—especially from those whom are most affected.

Two Essentials: Community and Communication

As part of my HIP fellowship, I get to interview leading practitioners and partners to learn more about the fascinating field of Health Impact Assessment. Two things stand out from my conversations as most important: community and communication. 

Tia Henderson, research manager at Upstream Public Health, says that the more she does HIAs, the more she is convinced that that the process must be owned by the community. Without community participation, she says, we can only speculate about health impacts, but integrating community members in the process bolsters the research and findings.

Sandra Witt, director of Healthy Communities (North Region) at the California Endowment, agreed, but added that community participation is not just about getting the best data, it’s also about equity. “The people most affected need to be present at the table,” and that people working in public health “need to be rooted in social justice.” This is especially of high importance because often times the field of public health can be disconnected from social issues that affect health.

Steve White, a project manager at the Oregon Public Health Institute, emphasized that HIAs are not only vehicles for research but for communication, so the assessment, recommendations, and reporting steps should carry substantial weight. Part of the responsibility to communicate, said Aaron Wernham, director of the Health Impact Project, includes forthrightly addressing opposing arguments because it helps build a more robust HIA. “Don’t work on an HIA where the holes are not addressed,” he said.

Everyone has provided insightful and useful recommendations. The responses are fascinating because they demonstrate the structured, yet fluid composition of HIAs. Interviewing HIA stakeholders has been especially helpful in deciphering whether I’m heading in the right direction with my own HIA project (which focuses on wage theft).

Finally, it reflects the strong interconnection that exists among various HIA organizations across the nation.

Health Impacts of Upward Mobility

The link between more education, higher income and better health is well established. But now, new research suggests that the process of upward mobility can also be taxing to the health and well-being of people of lower socioeconomic status.

In a New York Times op-ed, Can Upward Mobility Cost You Your Health? Gregory E. Miller and Edith Chen of Northwestern University and Gene H. Brody of the University of Georgia report findings from a long-term study of 489 African-American youth from rural Georgia: “Those who do climb the ladder, against the odds, often pay a little-known price: Success at school and in the workplace can exact a toll on the body that may have long-term repercussions for health.”

The article struck a personal chord with my own experiences in college. Because of my undocumented status, I paid my own tuition, but was denied research opportunities and participation in some programs. Many of my experiences parallel those of the young people in the study.

For example, the researchers write: “In our studies, most participants are the first in their families to attend college. . . Many feel socially isolated and disconnected from peers from different backgrounds. They may encounter racism and discrimination.” I, too, was the first in my family to attend college. When my mother was deported I felt a responsibility to get additional jobs to help with my family’s income, and still continue as a full-time student while actively participating in a support and advocacy group for undocumented students. My school, work, personal, and family obligations left me drained and with a poor sense of belonging.

The study also found that “behaving diligently all of the time leaves people feeling exhausted and sapped of willpower. Worn out from having their noses to the grindstone all the time, they may let their health fall by the wayside, neglecting sleep and exercise, and like many of us, overindulging in comfort foods.”

My experience with the undocumented student group confirms this; it was both demanding and empowering. We relied on our limited time to strategize ways to demand the same treatment and opportunities as our non-undocumented peers, advocated for state and federal policy related to immigrant rights, and worked to increase knowledge to high students about higher education opportunities.

Despite our diligence, ambition, and dedication, our fight-or-flight responses were always on. The next meal was sometimes uncertain, so as a natural stress response we often filled up at events with free food. This illustrates how stress, sleep deprivation, poor exercise, and inadequate nutrition affect weight, blood pressure, and other chronic illnesses—as the article explains.

The researchers offer ways to mitigate the harms of being in this situation — better health education, more checkups, classes in stress management. But I personally believe that those suggestions are like putting a Band-Aid on a deep gushing wound.

Problems brought on by inequitable institutions, such as education, cannot be solved solely through health education, health screenings, and mentorship programs. My peers and I knew plenty about health education, healthy eating and exercise, and stress management. The veil of chronic stress lifted only when I got my green card, when I stopped feeling like a pariah in constant fear of deportation, and when the doors to better job opportunities opened.

Understanding the social determinants of health — our living and working conditions, and the social, economic, political, and cultural environment — is not enough unless we also act to address them.  Health Impact Assessment is one of the tools that can gradually help us reach health equity because it aims to uncover the root causes of poor health.