Meet Bridgette M. Brawner, PhD, APRN

Gregg Masters  00:08 

This episode of PopHealth Week is sponsored by Health Innovation Media. Health Innovation Media brings your brand narrative alive both on the ground in in the virtual space for major trade show conference and innovation summits via our signature pop up studio. Connect with us at www.popupstudio.productions. I'm Gregg Masters Managing Director of Health Innovation Media publisher of ACOwatch.com and your PopHealth Week co host with my partner co founder Fred Goldstein, President of Accountable Health LLC, a Jacksonville, Florida based consulting firm in our continuing series on the impact of systemic racism inherent in our healthcare system. On today's show, our guest is Bridgette Brawner, PhD, APRN and Associate Professor of Nursing at the University of Pennsylvania School of Nursing. Dr. Brawner's specialty includes social justice through nursing, where data from geographic information systems are leveraged to develop interventions for urban populations that improve Family and Community Health and promote sexual health such as preventing HIV and other sexually transmitted infections, and via the broader lens of methods and models to improve the health of historically underserved people and communities. So with that introduction, Fred over to you help us get to know Bridgette M. Brawner,

Fred Goldstein  01:40 

Thank you so much, Greg. And Bridgette, welcome to PopHealth Week.

Bridgette M. Brawner  01:43 

Thank you for having me and for using your platform for this really important work.

Fred Goldstein  01:47 

Oh, it's really my pleasure. It's something that Gregg and I have talked about and decided, you know, as we said, for the next series of who knows how many months potentially, we're going to focus on this whole issue of racism, bias, health disparities, discrimination, etc. So I'm really glad to get a chance to talk to you, why don't we start with perhaps giving us a little bit of your background and the work you're doing it? The nursing program at the University of Pennsylvania?

Bridgette M. Brawner  02:07 

Yeah, definitely. So my name is Dr. Bridgette Brawner. I am an Associate Professor of Nursing at Penn Nursing, as well as a Senior Fellow in the Center for Public Health Initiatives at the university. And my research centers on health inequities. And I use that word inequity deliberately, because we're not just talking about differences in health. But these are unfair and unjust differences that are experienced by certain groups. And so for me, because these inequities are avoidable, I use research as an advocacy tool to inform interventions as well as policies that can help health and reduce risk. And so ultimately, the goal is to eliminate the ways that these like individual social and structural factors are causing people, particularly those in black and brown communities to disproportionately get sick and even sometimes die.

Fred Goldstein  02:56 

I actually saw your name in this article titled COVID-19 assault on black and brown communities in which they interviewed you. Could you talk through some of the statistics and issues that you're seeing? And then some of how you're trying to research that? Yeah, definitely so.

Bridgette M. Brawner  03:11 

I have not done directly any COVID-19 related studies, most of my work has been in HIV. But looking at the racial disparities data for COVID-19. It's like the same playbook plays out over and over again, regardless of what health condition we're talking about. And so when you drill down the numbers, let's say for Philadelphia, you know, you're seeing fatality rates from COVID-19, two to three times that amongst blacks is what you see in white populations, or even APM did some research and we're looking at the 1000s of lives, you know, that were lost, because of disparities that we're seeing in care. And they've even drilled it down by age where initially we were thinking that younger people would be less affected by Coronavirus, but they're actually seeing in younger demographics that there were death rates nine times that of whites among blacks, and I believe it was in the 25 to 44 year old age population. And so you know, we're seeing a lot, where there's just these differences, these inequities between racial and ethnic groups. But what I really want us to hang our hat on is that these differences that we're seeing are not reflecting race, right? Race is a social construct, that is not something that is biological or genetically driven. So the numbers instead of reflecting race, they're actually showing us racism, they're actually showing us what the shared experience of being black, Latino, Native American, you know, Asian in America, what that's doing to the physical body and how it plays out in our health.

Fred Goldstein  04:39 

And you mentioned a really good point, that while we're clearly seeing this with COVID, and it's getting a lot more attention, and I'm seeing it all over Twitter and in the press in the media about disparities. And as you said, the health inequities. It's been around in HIV for a long time and you study that even though we're not thinking about HIV. As much So could you sort of dive into that area and what we're seeing in HIV in terms of the differences in outcomes?

Bridgette M. Brawner  05:06 

Yes, absolutely. So when you look right, and you say, okay, African Americans represent 13% of the population, or when you're looking at late diagnoses, meaning that someone has been HIV positive for a length of time, and by the time they access the care system, they have already advanced in the state of the disease and are, you know, more likely to have worse outcomes. We're looking at the numbers, and it's something again, were from the early days of the epidemic, you know, just like we're doing with Coronavirus now, we were targeting people's behaviors. So we were saying, you know, well, what are those people doing over there to put themselves at risk. And when we do that, you know, we completely absolved and ignore the fact that things such as redlining controlled where people could live, you know, and not only where they live, but the types of resources and healthcare system infrastructure that was available in those communities. So it all the common thread that we come back down to is injustice, you know, historical injustice that has happened over time, and how until we get to those core root issues, whether it is HIV, diabetes, maternal mortality, you know, Coronavirus, we're always going to see this inequity between groups because people don't have the same basic rights, right, the same basic access to the things that they need to be healthy and thrive.

Fred Goldstein  06:27 

Right, so let's sort of dive into that a little bit. As you go down, and we'll talk social determinants of health now social determinants of health, and, you know, we recognize its its housing, its food, its access, its transportation, can you talk about specifically, the structural things that are creating those those problems down at that level?

Bridgette M. Brawner  06:47 

Absolutely. So if we start, let's say, with housing, we know that people who are unstabley housed have increased risk for a variety of different conditions. And that can come from, you know, the basics of not having shelter of not having food, of people having to either engage in different activities to make a living. So let's say with Coronavirus, they may be an essential worker in a grocery store or doing, you know, deliveries or something else. And so, by virtue of their work, they're being exposed to more people. And then they're living in an area where maybe there's overcrowding, you know, or they're in an apartment building where they're living with hundreds, sometimes 1000s of other individuals. So when you're talking about communicable, communicable diseases, in particular, it's almost a numbers game of like sheer exposure, right? The number of people that you're exposed to. And so when we look at housing and access to housing, it's not only where people live with the types of conditions that they live in, which also ties in you know, with work and employment, another determinant with employment is looking at, let's say, sick pay leaves. So people who, right now during this epidemic didn't have the privilege of working from home, they had to go to work. And we know that black and brown workers are disproportionately represented in that population. So with our social determinants, you know, there are multiple housing, economics, employment, the types of resources that are available in communities that drive and affect our ability to be healthy.

Fred Goldstein  08:15 

And you've obviously been researching this for a while. Many of us in the field have seen these issues, whether it was when I first worked in Medicaid and saw the differences in the issues that we we had to deal with to help the individuals first that then they could help themselves with health care, but try to solve those other things that were impacting their lives. Who do we need to get that message out to? Now? Who needs to hear this?

Bridgette M. Brawner  08:36 

That's an excellent question. So that's where the frustration lies, right? Typically, we do this and we're preaching to the choir, because there are numbers of individuals, hundreds of people who before me, right and even now have been doing this work for decades, they've been publishing, they've been researching, they've been, you know, activists on the front lines, and they either were not taken seriously, or people it was so much easier to just check the race box and say this is happening, you know, because people are black, or because people are Latino. And so now we want the masses to hear this message for people who have positions of power and authority, those who are making laws, those who create policy, those who are heads of organizations, who can do things like working towards stable housing, you know, and universal health care for all. So we want this to be something where we're engaging people who traditionally have not been a part of this conversation. And to make it clear, it's not that they were excluded. I think people were just living in their own lives, right in a different aspect of their lived experiences where their eyes weren't necessarily as open to this as it might be now. And so if we can engage more people, especially those you know, and I'll just say it why people with privilege and power and positions of influence to step in and to be able to say okay, what can I do within my sphere of influence, to bring about change and to make a difference or, you know, for those who have political power, what can I do you know, in my areas to make a difference and so that we can see to it, that in these areas where we're seeing injustice in these areas, you know, where we have this person gets this type of education in their neighborhood school while another person gets something, you know, completely different. How can we level the playing field so that it is more equitable for all?

Fred Goldstein  10:19 

And you said something I think is so important. You said, What can I do? And it's, you know, there have been words played in this for decades. And it really is about doing something, isn't it?

Bridgette M. Brawner  10:31 

Yeah. And I think sometimes it feels paralyzing, right? So the things that we're talking about are big. And it starts to feel like something that one person can't have control over. So when you look at macro level factors, right, let's say if we stick with the example of what mortgage redlining did, then and continues to do now, that sounds big. So what can I as one person do about the fact that there are people who have been relegated to live in certain areas, and anytime that we go to build those areas up? You know, through gentrification, we displace the original residents to make that happen? All right. So it may feel big and like, I can't do anything about that. But it takes one person having a conversation. You know, it takes one person working with a real estate development company that says before we, you know, look to have people move in here from outside of the community, let's work with people who are already here toward home ownership. Right. So  community redevelopment within the neighborhood. And so there are things that we can do. I think we just each have to really think strategically, as far as what are we good at? Where is our expertise? What resources are we tapped into, because truthfully, we have exceeded the timeline to do nothing, right? Things can feel big, and that can be very paralyzing. But we have come to a place where we literally as a nation, can no longer afford to not address injustice, because it is making us sick.

Fred Goldstein  11:59 

Right

Bridgette M. Brawner  12:00 

We're losing lives, you know, unnecessarily. And so if we can each just say even if I make one phone call, even if I watch one webinar, you know, even if I revisit the policies of my own business, whatever role we play, we each do something I truly believe that can make a difference.

Gregg Masters  12:17 

And if you're just tuning in, you're listening to PopHealth Week, our guest is Bridgette M. Brawner, PhD, APRN, an Associates, Professor of Nursing at the University of Pennsylvania School of Nursing.

Fred Goldstein  12:30 

So taking that a little further, what should the role of the healthcare system be and what should the healthcare system be doing?

Bridgette M. Brawner  12:36 

That is excellent, the health care system. So for me, as a nurse, I think we're really kind of like an anchor point in all of this, when we look at Coronavirus, and what's happening, we have just as a system failed, I mean, it's not even only on the system, there's, you know, higher level factors that went into play to get us where we are. But we had issues with people coming for testing and being denied multiple times, and not only denied, because the testing criteria weren't clear. But there were ways where implicit and explicit bias played out. So you see, an African American male who is let's say, overweight, has high blood pressure, you know, a history of asthma. And so he comes in with COVID-19 symptoms, and you say, oh, it's just bronchitis, you know, and so you send him home with a bronchitis regimen. And so I think within our system, we have to do a much better job of taking people's symptoms seriously of listening to what they're saying is going on with their bodies of doing complete and thorough workup, you know, and advocating for that. So that we're not just assuming what's going on, based on like these racial heuristics that we've been accustomed to, but actually letting the symptoms and letting the chief complaint speak, you know, to do what needs to be done and then holding our colleagues accountable, to speak up against discriminatory practices, but then doing that, like difficult, deep inner work to address our own implicit and explicit biases. Because when we think about it, right, like as a healthcare system, we know that is built in it has structures of racism and discrimination, but our licenses, especially for us as nurses, right, we have an obligation to our license to stand against those things at all levels, so that people can reach their full health potential.

Fred Goldstein  14:18 

And Dr. Brawner, you brought up the issue of nursing how easily, you know, you've got your doctorate in that and working as an associate professor, are there things that nursing should do differently or educational approaches we may want to put into the programs or things like that, to assist in this area?

Bridgette M. Brawner  14:35 

Yeah, I had the privilege of participating in a webinar for the American Nurses Association and we specifically talked about this the role that nursing can play in racial disparities and COVID-19 um, it's, it's free for those who wants to register and open regardless of ANA membership. So I would say anybody who is really interested in digging a little deeper than what we can do right now, I would strongly encourage them to watch that on the ANA web. sight. But to briefly say here, we can, again address like our implicit and explicit biases. So that means revisiting our nursing curriculum so that it's not just something that you get, you know, in one class on one day, where they say, hey, treat all people as individuals, you know, and thoroughly assess them. But it's literally threaded throughout from their, you know, entry to exit experiences, that they're getting content on racial injustice, that they're getting content on the social determinants of health so that people understand everything that their clients are bringing to them, I think we can also do a better job of preparing people for real world situations, you know, so know that the fact that racism and social determinants of health and all these other things affect health care, that then changes how we practice, it changes the way that we design our research studies. I mean, I think there needs to be things in place. So let's say for the academic environment, the Academy is not exempt from structural racism, either. So we have to revisit within our nursing schools, the way that white supremacy, racism and other ills have even negatively affected the training environment, right, negatively affected faculty who work in these places. And then students and staff who are engaged in them as well.

Fred Goldstein  16:15 

I know a lot of this is we're talking about it is social and putting in programs, things like that. You also do work with geo-mapping and GIS data. And obviously, technology and data is a big part of population health. How are you using that data? And what sort of things have you been doing with that?

Bridgette M. Brawner  16:30 

Yeah, so I really love maps, because they tell a story in ways that difficult to comprehend with words or numbers alone. And so let's say if we use Coronavirus, as an example, when you can have a visual, right of where the cases are, and then overlay that with factors like health care system access type of employment, it helps you start to see patterns of where things are happening where you may need to, you know, reallocate resources. And so you can also by seeing that leverage GIS to then locate community based organizations in those areas, and facilitate mobilizing their staff to then do education, testing, providing services, you know, we don't have to invent the wheel, we don't have to reinvent it. I mean, there are people who are already on the ground doing this work. And so technology such as GIS can be used to sort of find where these areas are, and then not only sort of like track clusters, but then monitor responses to any efforts that we do. And there's also the ability to do more sophisticated analyses so that you can even look at correlates or predictors of change over time. So I think, you know, as we begin to envision a new world and think about what are the things that we need to do to really make a difference moving forward? Yes, it's going to be important to have the racial data just because right now, you know, it's the proxy for racism until we get things right. But in addition to that, by using, let's say, GIS or even social media, we're able to more accurately engage with people in the spaces where they are, and then see what we need to do to make a difference moving forward.

Fred Goldstein  18:06 

Can you give some examples, perhaps you might have of things that are working or where you think they're getting better doing a good job and some of these programs?

Bridgette M. Brawner  18:14 

Yeah, so a powerful example here in Philadelphia, there's a group called the Black Doctors Consortium, and they started out doing Coronavirus testing with individuals like going out into the community. So instead of saying, you know, come to this healthcare system to be tested, they were set up in parking lots in different areas, meeting people, right where they were when able to kind of like backbone, bypass some of the barriers that we have to seeking treatment now, but I know from personal accounts that they have partnered with two of our largest churches in the city, Enon Tabernacle Baptist Church, as well as the Church of Christian Compassion. And as a result, they were able to test more than 5,000 people. And I believe, you know, the communities that they were in, it was predominantly black populations that were tested. And so by using that strategy, they brought Coronavirus testing to people, who again, were not being tested in other means, you know, these some of them were folks who had been tested turned away from the health care system, some were even people who had mistrust or distrust of the health care system, and so didn't want to go in, you know, to those settings for testing. And so this is like, you know, a concrete example of a way that we can partner with community entities and even faith based institutions, so that we can more efficiently deliver these essential public health services.

Fred Goldstein  19:32 

And it gets to a really interesting point. I've heard about it a couple times you see these approaches that say, for example, let's take health literacy. Okay, we want to go ahead and get out into this group and improve their health literacy. At the same time, there are others who say, well as a health care system, you just need to get your communication down to that level. It's your responsibility to meet their need. How do you think that plays out? Or is the differences there?

Bridgette M. Brawner  19:58 

Yeah, so health literacy in and of itself is really complex, right? Because there's the element of the healthcare system can produce something. But when we look at how I mentioned before structural racism, even in the health care system, a lot of times when that is produced, you have to be mindful of who was around the table, creating that content, right. And I am a community engage researcher. And so for me, everything that I do, needs to be informed by the population that I'm working with. And let's say even as you know, a black woman, if I do research with black women, my identity as a black woman doesn't mean that I don't also have to consult that population, for the work that I'm doing. So when we're thinking about health literacy, and creating content, if you're trying to do something, you know, in a Native American community, or an urban Philadelphia, black community, you know, a Latino community, you have to have individuals representing those communities and not just at you know, your like executive board or whatever level but the who are living, there working, there, you know, socializing there, because then when they're a part of creating the content, it helps to ensure that the messages make sense, right, that they're like culturally relevant and accessible, that is encompassing all of the things that are happening on the ground, and not just sort of, from our like ivory tower perspectives of what we think is happening. So I do think it's kind of like a dual approach, where you can have the system, identifying a need and saying, okay, these are some of the messages that we want to get out there. But there always has to be that validation, or that check or that input from the community expertise to make sure that what you're developing is actually going to make sense and be adopted.

Fred Goldstein  21:37 

And you sort of live that, as you said, You're a community engaged researcher, and I love that term. those terms. Do you see healthcare organizations beginning to do that much more? Or is it still early? Or where are we in that process?

Bridgette M. Brawner  21:51 

So that's kind of tricky. I think there are some who have historically done it very well, we have extremely successful models of academic community partnerships, you know, through like Penn, Temple, Drexel, speaking here, for the Philadelphia context. So there are ways where people in the academy realize I can have all of these degrees, but it does not mean that I know everything that I need to know, right about this issue that you're dealing with. And so there's, you know, in that respect, there are people who are doing a great job and who are doing it really well. Some of it, though, ends up being sort of like pro-forma, where I invite you, I invite, you know, one person to my meeting to say that I had a community representative. And then I move forward as though I had done focus groups with, like, 200 people. So there's people who are doing the work, but I think we can absolutely do a better job of not just engaging the community, but engaging them in meaningful ways. So let's say if you're running a research team, who's on your staff, you know, are you only staffed by people who do not look like the community that you're conducting research in? Are you you know, like, my work with us, for example, I had high school students who were hired and paid to be a part of the team, there were undergraduates, you know, graduate students, just so that people across all levels across all, you know, educational, socio-economic backgrounds, were a part of the team. So that way different perspectives are represented, you know, as we were developing interventions, or coming up with surveys, even creating our parents and recruitment materials, it's so important to have those voices.

Fred Goldstein  23:22 

Do you think, given where we are now and the issues raised, it's really, you know, come to the fore both because of COVID and the Black Lives Matter movement? Or is this gonna get us to the shift you feel comfortable positive that we're gonna move this time?

Bridgette M. Brawner  23:39 

Yeah, I really, I hope and pray. So I, you know, to be transparent, it gets exhausting as a black woman, you turn on the TV, and it's like, you know, your people are dying from this disease your people are being killed, you know, unarmed by police. Like it's just a constant death and destruction narrative, even for, you know, my Latino, family, friends and colleagues, where it's like, people are still in detention centers, right, like, there's so much going on. So I think and I'm hoping that we have reached a moment of like, critical consciousness as a nation, to where we say the things that are happening have been happening for so long, but it doesn't mean that we're going to continue to allow them to go there, right because the inclination right now everyone is rushing to quote unquote, go back to normal. They just want things to be you know, how they were before Coronavirus, hit and for me pre Coronavirus wasn't necessarily a beautiful world. Like it was nice to have some of my loved ones still living. You know, for those that passed from COVID

Fred Goldstein  24:39 

Right there was a lot that was going on, that still was not good or healthy for people who looked like me. So I do think now because we were quarantined, you know, and we were home and for some individuals, they were more of a captive audience, people who may have been able to turn the channel stop scrolling through their feed, you know, find other ways to disengage from the conversation, it's been put so upfront in their faces, that they now feel, you know, reinvigorated and charged to do something because they're finally seeing the injustice. You know, for those who would say, Oh, well, if you just comply, you know, police officers won't bother you.

Bridgette M. Brawner  25:18 

Or if you just...

Fred Goldstein  25:19 

Right.

Bridgette M. Brawner  25:19 

You know, eat healthy, you don't have to worry about diabetes, they're beginning to see like, wow, there's a piece of this story that because of my lived experience, I was never privy to, you know, and when people even tried to tell me, because of my own biases, and my worldview, I shut it out, because I didn't see a place where that was possible. But now they're starting to consider other alternatives.

Fred Goldstein  25:42 

And you raise an issue that we just have a minute or two here to discuss. And you talked about the stress that you feel that you're experiencing because of the message. And obviously, that stress been there for a long time, just from the inequities that have existed? Are you seeing an approach to begin to try to bring some additional behavioral health and mental health services and make those more available to the community as the stress level rises? Because of what's going on?

Bridgette M. Brawner  26:06 

Absolutely. So I have seen, I haven't seen the legs put behind it yet. But I have seen more calls, even to the federal level for funding to be put toward behavioral health. This is absolutely something when we think about racial trauma, when we think about you know, weathering effects of just constantly being conscious of what's happening and the effects and toll that that takes on the body, we absolutely need to make sure that individuals have access to affordable if not free, therapy options, right? We have to get messages out there. So that people can engage in practices to counteract the trauma that they're experiencing, whether that's yoga, meditation, prayer, you know, spending time outdoors. And so I do see there is an uptick of interest, you know, of making these options available. And even for our health care providers, who have been on the frontlines of this pandemic, they you know, PTSD is real. And so when you have 4, 5, 6 people die in one shift, when before that was maybe only happening, you know, once a week or in a month, they're going to need support as well. And so yes, there have been calls to make that happen. And I'm just hoping that people will follow through, because all of these things that we're talking about needs to have dollars behind it, right. There needs to be funding investment, instead of just thoughts and well wishes and you know, hashtags, so that we can see things change.

Fred Goldstein  27:24 

It really is a question of doing something and Dr. Brawner, I want to thank you for coming on. It's been fantastic to have you on PopHealth Week. Thank you so much for joining us.

Bridgette M. Brawner  27:32 

Thank you for having me. I was honored.

Fred Goldstein  27:34

Turn it back over to you, Gregg.

Gregg Masters  27:36 

And thank you, Fred. That is the last word on today's broadcast. I want to thank Bridgette M. Brawner, Ph.D., APRN, Associate Professor of Nursing at the University of Pennsylvania School of Nursing for her time and insights today. For more information on Dr. Brawner and Penn Nursing's work in this space do follow them on Twitter via  @DrBMBrawner doctor BM Brawner and @PennNursing respectively. And for more information on Penn nursing, go to Nursing.UPenn.edu. For PopHealth Week my colleague Fred Goldstein and Health Innovation Media. This is Gregg Masters saying bye now.