Advancing Health Equity Through Disruptive Innovation

JOEL BERVELL: My guest on this episode of The Dose is Dr. Chris Pernell, a public health physician, professor, thought leader, and the director of the Center for Health Equity at the National Association for the Advancement of Colored People, the NAACP. It's her job to move the needle on health care access and the widespread disparities in health outcomes. Structural inequities shape the health journeys of many people of color, from the moment they're born, and often, even before. For Black Americans, this means a greater burden of disease, and on average, lives that are cut short by eight years compared to their white American counterparts.

The NAACP is recognized as the first civil rights organization in the United States, founded over 100 years ago, in 1909, by a multiracial group that included W.E.B. Du Bois and Ida B. Wells. The emphasis of the NAACP has always been on safeguarding the constitutional rights of people of color. That language is literally in the name, and that mission continues today. We'll talk about what the NAACP is doing right now about health equity and disparities, and what the road ahead might look like in the quest for innovative solutions and depending on the outcome of the upcoming elections.

Dr. Chris, thank you so much for joining me.

CHRIS PERNELL: My pleasure. Really excited about chatting today.

JOEL BERVELL: Absolutely. Well, you are the top medical advisor to one of the most high-profile nonprofits in this nation's history. We live in a very complex health policy landscape today. Can you talk about how that shapes the way you approach your work?

CHRIS PERNELL: Definitely, it is a high honor for me as a public health physician, and especially as a Black American, to be in this position of agency to be able to inform, influence, shape, and help determine how the NAACP executes on issue and policy advocacy, especially as it relates to health equity, health justice, racial justice, if you will. And we are at a ripe time, and I will use that language intentionally, in our nation's history, and even globally, coming out of the pandemic, the coronavirus pandemic, and the public health emergency.

It is so important for organizations like the NAACP to be able to translate and communicate for the public and, in particular, those historically excluded groups that are impacted by policies, impacted by laws, impacted by events, occurrences, and crises. And so, basically, we focus on health in all policies, and so, it does not explicitly have to be related to health care or health care access, but as Daniel Dawes would say, how those political determinants of health are impacting Black communities, brown communities, those who are from those historically excluded groups, and to be able to say, how do we navigate this policy landscape, how do we navigate this practice landscape, and how do we dismantle and disrupt the system of racism?

JOEL BERVELL: Absolutely, the political determinants of health, I love that, because it goes into so much of the beyond. And so, how are you navigating right now? What are the types of things that you're doing to do that?

CHRIS PERNELL: When I started my tenure with the NAACP, and I'm still young in my tenure, I'm about seven months in, I inherited four strategic pillars, and these strategic pillars guide our mission and mandate, and what the work actually looks like. So we're drilling down and doubling down around equitable access to care and equitable health outcomes, definitely focusing on equitable food systems, because food is medicine. We talk a lot about that in public and population health. We're also focusing on what we describe as an inclusive health care system, provider availability, social and cultural fluency, as I say, and others say, cultural responsiveness or cultural competency, as well as looking at healthy people, healthy communities, and health in all policies.

So whether we're talking about states who have failed to expand Medicaid, or whether we're talking about national legislation and the pending farm bill, and how many Americans access SNAP, the Supplemental Nutrition Assistance Program, or if we're talking about health literacy and wanting our member leaders to understand how a caste system in the United States, how a system of racism, even genderism, sexism, classism, ableism, if you will, just to name a few, impacts their health outcomes. And we've said for so long that place determines health outcomes, zip code determines longevity or life expectancy. Zip code determines whether or not you have certain cancer disparities at a higher rate than other communities, even dementia.

So sometimes it's purely policy, advocacy, and we have a seat at some very large tables, whether those are with the White House administration or with elected officials, or whether we are trying to influence the practice space. And finally, I'd say, we're drilling down on what will be. Everybody, with bated breath, is paying attention to this next presidential election, and while the NAACP, we don't endorse a particular candidate, we say we're not partisan, but we are definitely political. Because of those political determinants of health, we want people to understand what's at stake around reproductive justice, around Medicaid disenrollment and the ACA [the Affordable Care Act], and ultimately, Project 2025, if certain persons are elected or administrations are amenable to these type of oppressive policies, what that means for the Black community, what that means for health and racial justice.

JOEL BERVELL: Absolutely, wow, I mean, there's so many things that you said in there that I could pick up on. I think for me, one of the things that resonated is thinking about how a zip code is a better determinant of health in someone's genetic code. I say that all the time. You explained it and pointed out the different policies that you're trying to address that are looking at that. I'm curious, how do you do that, though? Because we talk about all these things we're wanting to do, we're talking about having a seat at the table in Washington, but how do you actually go in and address and make change to people's hearts and minds in Washington? How do you address the problems in suburban areas, in rural areas, in big cities? How are you navigating these different spaces?

CHRIS PERNELL: Yeah, I like to talk about power, Joel. In public health, we say, share power, share power equitably, and share power inclusively. Because in caste systems, in caste societies, with racism being an example of a caste based on a race definition, we have to understand, who has the power, and what type of power are people amassing or do people have access to? There's economic power, there's political power, there's community power, there's the power in narrative or lived experiences. So whether or not you're talking about a federal issue, and I'll give you an example, a federal issue that we've spent a fair amount of issue and policy advocacy around is trying to emphasize before the White House, the need in this current administration to finalize the FDA draft rule around banning menthol products. We know that menthol, through Big Tobacco, has been predatorily focused in Black and African American communities, poorer communities, women, youth, certain immigrant groups.

So what do we do in the NAACP? We help to make the case. We make the case through data and impact stories, we look at where our member leaders are, what communities do they live in, and what are those prevalence rates around smoking, and in particular, the morbidity or mortality associated with menthol products? And we help the administration to understand, what does that look like nationally? And it's also coalescing like power, whether those are other advocacy groups or other elected officials, whether at the mayoral level or the state level, to say to a federal actor, this is why this is important. And unfortunately, that was kicked down the road, and that delay, we say, continue to contribute to Black morbidity and mortality. And I'll say this last thing and I'll pause: Black people continue to live sicker and die sooner than almost every other group in the United States.

JOEL BERVELL: Thank you for that answer, because I think it laid out perfectly, a great example. And I think a lot about menthol cigarettes, too, I actually have made a lot of videos about it, about how, for example, tobacco stores are located near schools that have more Black students, and are more likely to promote menthol cigarettes through advertising and discounts, and that's despite tobacco being the primary cause of cancer death in the United States. You also described yourself as a board-certified physician executive and systems practitioner, and we've talked a little bit about systems, but can you share your thoughts on why, as a physician executive, you consider looking through a systems lens as so integral to your work?

CHRIS PERNELL: This is fascinating for me, because if I reflect back, and I recently had an opportunity to sit across from my childhood hero, we were on different sides of an issue, but to reflect back on why I first wanted to become a physician. Like many children, I had romanticized the notion of healing, I had romanticized the notion of what it meant to be a doctor. And since the sixth grade, I actually thought I would be a neurosurgeon. But it was as life also happened to me, Joel. I have postural orthostatic tachycardia, POTS, as it's also known, and I was formally diagnosed in my internship year at UCLA.

It was a harrowing experience as a Black woman and as a Black physician trainee. No one believed me. They told me it was in my head, though I went from a seated position to a standing position, and my heart rate would race to almost 160-plus beats per minute, my heart started to fatigue, at one point, my ejection fraction drops. For those of you who don't know, that's talked about the muscular function or capacity of the heart to deliver blood to the organs and throughout the body. So I was suffering, and I was ready to take a journal article into my cardiology appointment to say, listen to me, hear me, believe me, validate me.

And it was life experiences like that, I had to go on disability, this was before the ACA or Obamacare, so ultimately, I became uninsured. So as I stepped back and began to see how policy, if you will, interacts with practice, interacts with people, interacts with politics - because those are all discrete and different, but working together - that's how a person truly has their health shaped or their health influenced. So as a physician, I ultimately decided to flip my training once I was well enough to go back into it, and to become a public health and preventive medicine physician.

And we are unique among our peers, in that we are trained in systems thinking. So I always tell people, I treat systems, and sometimes you got to make those systems bend, and other times you got to disrupt those systems, innovate and invent, and create and design. And as a leader, I've led at various different levels, whether it's in a state hospital, or whether it's in a national civil rights organization, you got to understand those levers of opportunity and action to achieve a stated goal.

JOEL BERVELL: There's so much in there that you said that I resonate so much with. One, thank you for sharing your story, that's a powerful story, and hearing how you've used your own personal experience to further your mission of changing the lives of other people, not just individually, but systemically. I want to transition to seeing the links between the NAACP's areas of focus and the inherent work. So the mission is, confronting and correcting for the systemic racism in this country. That means housing, economics, education, all of these things are linked and within the scope of work. How does health care compete for internal resources, both funds and bandwidth, of your professional staff and board?

CHRIS PERNELL: I can tell you right now, health equity is fundamental to the mission and the mandate of the NAACP writ large. The NAACP, in thinking through, how do you remain a future-first, forward-leaning organization, with this historic and very storied past, how do you do that? So it puts health equity as one of its centers of hope or centers of innovation, and right now, we are competing for the imagination of innovators. We recently announced at our 115th National Convention, we have a nearly $1.8 million partnership with Sanofi that'll allow us to do place-based community activation work across the United States, reflecting on data sets like the Black Progress Index that we did in partnership with the Brookings Institute. So I'm highlighting those things because the NAACP is able to use its muscle.

JOEL BERVELL: Absolutely, and can you tell me about some of the accountability measures that you see as effective in health care?

CHRIS PERNELL: Oh, definitely. So as a person who came out of the hospital sector within health care, I was in the hospital sector during the majority of the pandemic, and living through that public health emergency as a physician executive. And so, I can tell you, first and foremost, when equity is not a part of the triple bottom line for an organization, it's an afterthought, it's symbolic, it's ceremonial. So the way that we're going to drive accountability in health care is making sure that equity is cooked and baked into the operations of an organization.

And this is going to be a new frontier even for the NAACP - and I have keen insights around this as a past health care administrator - how are hospitals accredited? How are hospitals given their certificates of occupancy? How are hospitals able to do the work and the business and the service of providing care? And if equity is not a part of how we evaluate safety, how we evaluate quality, then those hospitals are going to fail in delivering culturally responsive or tailored care. So we're looking at metrics such as those, we're looking at indices like the loan index, how JCAHO is using equity in its accreditation processes, how CMS is using equity in perhaps its star ratings and other ways that it evaluates quality of care. That's the lever of change or action, if you will.

JOEL BERVELL: Absolutely. And you've previously used the term toxicity when you talk about community health. What do you mean by that, just for our listeners, and how should we think about confronting and abating that?

CHRIS PERNELL: Yeah, so toxicity is when you have an accumulation of stressors or accumulation of exposures or an accumulation of factors. And then, yeah, there's a safety net, but still, there are holes in that safety net, and that population falls through that hole. So successive levels of gaps and deficits allow people to have accumulating exposures to events, to conditions, to settings, to policies that shorten their lives and cause them to live sicker. Racism in and of itself is a toxic system. And the last thing I'll say, policy violence. Policy violence is, do people have access to care? Can they afford it? Is there a universal ticket or not? And when they have that care, is that care being performed or exercised equitably? That's what I'm talking about when I'm thinking about toxicity, the toxicity of oppression, if you will.

JOEL BERVELL: That's so helpful to understand and to lay that out. What are programs on the ground that are working to name, confront, and shift this toxicity that you're talking about?

CHRIS PERNELL: The beauty of the NAACP in particular is that we have these experts on the front line of community. We have member leaders, we have over 2,000 units or branches across the United States, we have over 2 million members, and these members are organized at their local level, and as it relates to health, you may find people doing the work of direct access, making sure people are connected to care.

Remember, I spoke about that Medicaid disenrollment issue, we saw during the pandemic, protections put in place where states could not kick people off of their Medicaid, but when those protections expired as of April 2023, we saw a precipitous decline in Medicaid. So we have member leaders, we have member leader activists on the front lines of community in their states, either actively trying to get Medicaid expanded, or actively advocating before their governor to say, hey, we need to reform the eligibility system. We have people thinking about equitable food systems. We elevated an urban farming initiative, the Obodo Collective, Black women urban farmers, ensuring that people within the communities of Las Vegas have access to healthy, affordable, nutritious food.

JOEL BERVELL: I'm getting chills listening to you, because you're just dropping so many gems about ways we can be improving these systems overall. I kind of want to ask about scalability, though, for these. How does that come into play when the NAACP is thinking about programs it's supporting or amplifying, and also, the ones that you're looking at and find interesting? Are they able to be scaled, replicated, here in the United States, across the nation, but also, even globally, when we think about how systemic disparities exist?

CHRIS PERNELL: Yes, so scalability is the magic word, if you will. Sometimes when it is that signature partnership, like in our Santa Fe partnership, we're looking at anywhere from 10 to 15 cities in particular where we want to be able to glean insights through community engagement and community activation models, match that up against data sets like the Brookings Institute's BPI that we've done in partnership, that looks at the structural or critical success factors that promote Black longevity, and then, use that information to have, if you will, a toolkit, a toolkit that other cities can then begin to reap the insights or the success stories from to say, okay, this is how we build a path forward.

Back when I was doing my training in public health at Johns Hopkins, I came up with this acronym, HUT versus HTT: "households under threat" versus "households that thrive." So through partnerships in the NAACP, we can take an idea like that and put some muscle behind it and begin to deliver data, place-based data, to say, this is what has worked here, this is why it has worked here, and through partnerships, whether either with the Robert Wood Johnson Foundation and/or others like I have named, we can begin to scale that across these United States. We've done things around Medicaid disenrollment with the likes of UnidosUS, NAN, and NCNW, and others. How do we come together and coalesce in understanding and use that understanding to speak truth to power, to demand accountability, and to produce systems change?

JOEL BERVELL: Wonderful. People can't see me, but I'm nodding my head over here a lot. I want to switch gears a little bit and talk to you about colorectal cancer screening successes and challenges. Earlier this year, in the spring, I spoke with Dr. Folasade May on this podcast about her work in her lab at UCLA, the real challenges in this work. From your perspective, what is effective, especially in reaching young adults, in efforts to find environmental toxins that might be driving a spike in cancers, digestive cancers, in people under the age of 50? And so, that's something that's especially impacting people of color.

CHRIS PERNELL: Definitely. So, you know, I sit on the American College of Preventive Medicine's board; I'm a regent at large. These are conversations that I have deep in the heart of community, helping people to understand risk, helping people to understand how risk is formed, how we prevent the formation of risk, how we mitigate risk, and how we begin to identify disease when it is present or detected, and get people into treatment when it is diagnosed.

I'll talk about it personally. I remember when my physician first said to me, "Chris, I think it's time for you to get your colon cancer screening, I think it's time for you to get a colonoscopy." And I said, "Hey, doc, I'm not sure it's time for me to do that." Now, we're talking about a conversation I had when I was roughly 43, I'm about to turn 49. And I was like, "Data shows that we're not necessarily sure that we need to do it this early." And he's like, "No, Chris, I want you to think about this through the lens of the risks that you are exposed to or have been exposed to in community, whether those are environmental risks, or whether those are risks due to health behaviors, diet and nutrition, and physical activity." And he and I began to have this back-and-forth conversation about the accumulation of risk and what that looks like across different groups. And so, finally, I had to succumb, unfortunately, because I got diagnosed with a vitamin B12 deficiency within months of this conversation, and that bought me an immediate colonoscopy, which, it was curative, it was a treatment procedure, because I had polyps.

Here I was saying I don't think I need it, but I had polyps, and I want people to understand that, because I thought I lived a pretty healthy life. I thought I was active physically, I thought I was eating a diet rich in fiber, I thought I was restricting animal fat, but I had already had an accumulation of risk in my body. And we have to begin to understand how environmental exposures or place-based conditions or settings that certain populations are predominantly or at risk of in disproportionate numbers, what does that mean across the spectrum? Not just the individual, but the spectrum of that population.

And that's why, with a spike in early onset cancers, why it's so important when we look at cancer disparities, of which colorectal cancer is one, that we begin to decipher for the public what that means. And that's another area that we in the NAACP, specifically in the Center for Health Equity, we're going to be leaning in. We were already thinking through a series, perhaps under our Let's Chat moniker, to cultivate a literacy and an efficacy, but it could not be more apropos or spot on to be having this conversation because of what we're seeing, the trends in the data.

JOEL BERVELL: As we begin to wrap up, you've talked about some of the people that have been leaders in your own mind that impacted you and guided your journey. I'm curious, who are some emerging leaders in this space that you're excited for in advancing the work alongside of you and the NAACP?

CHRIS PERNELL: First and foremost, I got to give a big up to our member leaders. Really, I am in awe, and let me explain what I mean by that, because so often, when we do the work of health equity, we sometimes think of physicians or other health care providers, or we think of policy professionals who can help to articulate or to drive a collective understanding. But it's really the people who are able to harness the power of their stories, the power of their lived experiences in their narratives, that impact decision-makers or policymakers. And I see that unfold every day in the NAACP. So I am encouraged by the groundswell of direct action that's happening in community, especially during this electoral cycle, where you see issues around reproductive justice, access to care, persistent and pervasive disparities in care, and medical debt as an economic justice issue, coming to light into the full circle.

And then, otherwise, I think about some of the people who have come of age, if you will, in this practice, right alongside me. I go immediately to Dr. Torian Easterling, a dear friend and a peer, someone who's leading locally, who has been a part of the New York City Department of Health and is also in the health care sector proper. And then, I want to think about some of those activists on social media, or those innovative companies, if you will, in digital tech spaces, like Health in Her Hue. I am in awe of Health in Her Hue because, when I think about the brilliant young Black woman who started this, I think about that NYU grad student who sat in my class. She was her. Right?

JOEL BERVELL: Absolutely, thank you for sharing those thoughts, and I'm so glad you shouted out Health in Her HUE, too. Ashlee Wisdom, we had on one of our earlier podcasts, she's absolutely incredible, doing amazing work. But Dr. Chris, I want to say thank you so much to you, as well, for sharing your story, for being so vulnerable with us, too, and connecting that to the greater work that you're doing at the NAACP and beyond, because we know you're not just from one place, you're everywhere. But thank you so much for the work you're doing and for sharing your thoughts with us here on this podcast.

CHRIS PERNELL: Thanks for having me. I stand on broad shoulders.

JOEL BERVELL: This episode of The Dose was produced by Jody Becker, Mickey Capper, and Naomi Leibowitz. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for art and design, and Paul Frame for web support. Our theme music is "Arizona Moon" by Blue Dot Sessions. If you want to check us out online, visit thedose.show. There, you'll be able to learn more about today's episode and explore other resources. That's it for The Dose. I'm Joel Bervell, and thank you for listening.

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