Partners for Advancing Health Equity

Welcome to Partners for Advancing Health Equity, a podcast bringing together people working on the forefront of addressing issues of health justice. Here we create a space for in-depth conversations about what it will take to create the conditions that allow all people to live their healthiest life possible. Partners for Advancing Health Equity is led by Tulane School of Public Health and Tropical Medicine, is a part of the Tulane Institute for Innovation in Health Equity and is supported by the Robert Wood Johnson Foundation.

Pathways to Health Equity with Dr. Paula Braveman
Episode 4: Pathways to Health Equity: Dr. Paula Braveman

August 25, 2022

In this episode of the series, Pathways to Health Equity, we speak with Dr. Paula Braveman, Professor of Family and Community Medicine and Founding Director of the Center for Health Equity at the University of California, San Francisco (UCSF), about her life experiences and their influence on her path in the field as well as her thoughts on the past, present, and future state of health equity. For more than 25 years, she has studied and published extensively on health equity and the social determinants of health. Full bio:

Papers discussed in this episode:

  • Systemic and Structural Racism: definitions, examples, health damages, and approaches to dismantling.  Health Affairs 2022
Episode 4: Transcript

[00:00:33] Thomas LaVeist: Hello and welcome to the partners for advancing health equity podcast. I’m your host, Thomas LaVeist Dean and Weatherhead presidential chair in health equity at the Tulane University School of Public Health and Tropical Medicine in New Orleans.

[00:00:52] Thomas LaVeist: I’m honored to be speaking today with Dr. Paula Braverman. Dr. Braverman is professor of family and community medicine and founding director of the center for health equity. At the University of California in San Francisco for more than 25 years, she studied and published extensively on health equity and the social determinants of health. Her research has focused on defining, measuring and documenting socioeconomic and racial, ethnic disparities, particularly in maternal and infant health.

[00:01:24] During the 1990s, Dr. Braverman collaborated with the World Health Organization, staff in Geneva to develop a global initiative on equity and health and healthcare. She’s been the research director for a national commission on the social determinants of health in the us sponsored by the Robert Wood Johnson foundation and throughout her career. Dr. Braverman has collaborated with local state, federal and international health agencies to translate research into practice with the goal of achieving greater equity and health. Thank you for meeting with us today, Paula.

[00:01:57] Paula Braveman: My pleasure,

[00:02:01] Thomas LaVeist: Paula, ya know we’ve known each other for some time now, but it occurs to me that I don’t know a lot about your background. where are you’re from where did you grow up? your parents, where did they come from? Tell us your story.

[00:02:13] Paula Braveman: When I was born my parents and my older brother, lived in a Boston slum with my grandmother, my maternal grandmother. and I guess when I was about one and a half years old, we became more upwardly mobile, and then we lived in trailer parks for the next few years. but ultimately settled in north Miami, Florida, a, white working-class suburb of Miami at that time.

[00:02:45] Miami is still very segregated, but even more so then, we spent summers, in the Boston slum with my maternal grandmother. but the school year was in Miami, about my parents. My father didn’t complete the 10th grade. He was too rebellious getting into trouble all the time. And, got fed up with teachers telling him what to do. So, he hadn’t finished the 10th grade My mother had graduated from high school would have given her eye teeth to get to go to college, but that wasn’t in any way, a possibility, for my family.

[00:03:24] Now my mother was a homemaker. my father sold advertising for small town newspapers. and was very ashamed of what he did because he was a profoundly idealistic person, I think, but he, somehow couldn’t find his way to work that would let him express, his idealism. and he made very decent money.

[00:03:51] at this job, he had selling advertising to, small town newspapers. And that was a big lur, perhaps, if he had persevered more looking for another niche, one that, would let him express, his sense of social responsibility it might’ve gone better for him.

[00:04:09] Paula Braveman: But as I grew up, I saw how bitter he was and how unhappy. And I vowed to myself that that wasn’t going to happen to me. I work that would be really meaningful to me, because I saw what it did to not have that.

[00:04:27] Thomas LaVeist: So, is that what drives you to do the work that you did or have been doing over the years?

[00:04:37] Paula Braveman: I think it’s fair to say. Yes. Yeah. I think it is.

[00:04:42] Thomas LaVeist: Did you have siblings?

[00:04:44] Paula Braveman: An older brother.

[00:04:45] Thomas LaVeist: So, with that background, your parents were able to produce a daughter that did go off to college apparently and obviously succeed spectacularly. what do you attribute that to.

[00:04:58] Paula Braveman: I think it reflects in large measure, how much are they wanted me to lead a different life from theirs and to succeed. So, there was a lot of encouragement about school and education was just so highly valued, and not taken for granted.

[00:05:17] Thomas LaVeist: Yeah. So, growing up in north Miami and in, Boston, these were not environments. I would imagine where there were a lot of college educated people living. so that influence came mainly from the home.

[00:05:31] Paula Braveman: Came mainly from the home, but I think it also came from seeing what the alternative was. If you didn’t get an education, that was pretty motivating also.

[00:05:41] Thomas LaVeist: Yeah. So, after you graduated high school, you went off to college. Where’d you go to college?

[00:05:29] Paula Braveman: I went to Swarthmore college right outside Philadelphia.

[00:05:50] Thomas LaVeist: Yeah. And why did you wind up at Swarthmore? The fighting little quakers, is that right? Is that the mascot? Yeah, shout out to Swarthmore.

[00:05:29] Paula Braveman: I didn’t know people who’d gone to college except I guess perhaps the teachers that I had in high school. So I didn’t know about what different colleges were like and I participated in a summer program at Cornell University the summer before my senior year in high school. It was very high powered program where half the kids studied the, the writings of uh, religious mystics to the writings of those who had taken psychedelic drugs and written about their experience uh a lot of kids it was a very selective programs nationally they selected kids largely on SAT scores and a lot of those kids talked about Swarthmore and the education was great the atmosphere was very focused on the academics and on thinking big thoughts.

[00:06:56] Thomas LaVeist: Well, it seems like you’ve fell it to the right crowd, peer pressure can actually be good sometimes apparently.

[00:07:05] Paula Braveman: Sometimes

[00:07:07] Thomas LaVeist:  So after Swarthmore, then where?

[00:07:09] Paula Braveman: At Swarthmore I majored in philosophy and that’s what I thought I wanted to do was be a philosophy professor. But this was the years, 1966 through 1970. And there were some things going on in the world, including in the US. And I think that was very effected by. the anti-Vietnam war movement, the civil rights movement, people at Swarthmore were very active in both those movements. And I think by the time, I reached spring of my senior year at Swarthmore, I was feeling like becoming a philosophy professor was a bit too removed from the fray. but I didn’t have a clue at all what the alternative would be. and I did have a boyfriend who was much in the same situation and we went seeking the answer, where is it that we, could plug in and, make a contribution to struggles for social justice. And yeah that might be a longer story and but the podcast we have time tell.

[00:08:18] Thomas LaVeist: We’ve got time and I think you’re a very fascinating person So we are happy to hear as much of it as you’d like to share. So where did you and this boyfriend decide was the place to go for you to find where you would make your contribution?

[00:08:30] Paula Braveman: Well, we didn’t really decide, it was decided, I think for a number of reasons, I hope that there’s no really young people who are going to be listening to this podcast. Because when I say that we basically, we hitchhiked around for about four months or so. it was a lot safer to hit it that it’s now my remarks are directed to the, the young people there don’t do what I did. It was a lot safer than that was something. It was a lot safer than that was something, there were a lot of young people like my boyfriend and me who were on the move, via hitchhiking. at that time, it’s too dangerous now. so, we hitchhiked around, we hitchhiked, up into Canada and across all of Canada and then down the west coast and backed up the coast and we ran out of money in Portland, Oregon.

[00:09:22] and my boyfriend had a friend who was living in a house with a few other people, and they had a spare bedroom. and, so, we settled there. They had some brief interludes where we tried our hand at being, farm workers, and found that we were really terrible terrible at it. And this was 1970 and, working in a factory, which had a certain romantic appeal, knowing nothing about, what it would feel like to work in a factory that wasn’t an option.

[00:09:55] Paula Braveman: Then they were laying people off, from factory jobs, in 1970, so we went to, temporary agencies, to find work. And remember in my first visit to the temp agency, the agent there told me there was just no possible way that she was going to send me out to an office, even though I had the skills, because I looked like a hippie. Look at your hair, look at your clothes, look at your shoes. I can’t send you out to an office. So that was very discouraging. But then a week later I got a phone call and she said, we have the perfect job for you at the hippie clinic This was a clinic. spring up around that time, towards alienated youth runaway. And they needed somebody who was, an all-around assistant, read and write and type a little bit. So, I got this job at this clinic and, my boyfriend and I started reading things that were coming out of, working for justice in the health sector.

[00:11:04] Paula Braveman: And we started, even though we didn’t want to be at a clinic for alienated youth, our whole lives, looking at what was happening elsewhere, we got pretty excited about being in the health sector it was a time when the black Panthers had free clinics, in communities, women were organizing self-health clinics.

[00:11:30] a lot was going on, an organization called health pack was publishing these brilliant analyses of the health sector one in particular called billions for band-aids, which I think would still be very relevant now. So, we got interested in the health sector and, tried our hand at being a nurses aid, at the veterans clinic, because I think I still, in my mind, the truly worthwhile thing to do would be an organizer and a working class heroin, I think I found after a year and a half of,  working as a nurse’s aid at a veteran’s hospital that, um, I’m not a talented organizer at all.

[00:12:26] Paula Braveman:  I think that job as a nurses aid and really feeling what it felt like to have a job that was really low on the totem pole, made me very seriously reflect on whether that’s what I wanted for my life. And I started thinking about what I could do. Given the fact that I did have a degree a college degree from Swarthmore.

[00:12:53] I had privileges that none of, the people I was working with who were nurses aid, they didn’t have those privileges and, reading about Norman Bethune, the Canadian surgeon who, went to China and, provided medical services that helped the Chinese revolution and other fables, like that started to think about, the possibility of going to medical school, and, to embrace it. So not your usual. Route at all and if somebody had said to me before then that I would wind up going to medical school and being a doctor, I would have been very offended, because it was too much like being a plumber.

[00:13:39] Paula Braveman: I thought of myself as an intellectual. But there I was taking advantage of the privilege that I had.

[00:13:45] Thomas LaVeist: Yeah, And where’d you go to medical school,

[00:13:46] Paula Braveman: Here at UCSF University of California, San Francisco.

[00:13:50] Thomas LaVeist: But So, you just made a comment taking advantage of the privilege you had, which what you did this swamp from a degree was a privilege. And he was able to use that to move from this, low wage employment into medical school. But I would also notice that it’s just looking at your career. you’ve used your privilege as a professor at a major medical school, I think to advocate for health equity. So, I think in many ways, I can see the pattern beginning from Boston and. Miami all the way through your days, hitchhiking through North America, as long as you can call yourself a hippie, you just said you looked like a hippie.

[00:14:29] And, so your early work, I’d asked you to share a few papers with me that you thought was illustrative of the arc of your career and the early paper was work on, health insurance among, the impact of pregnancy outcomes among women that did not have health insurance in California.

[00:14:46] So tell me about that paper. What were the findings there and why did you think that was a critical paper for us to talk about today?

[00:14:54] Paula Braveman: It was, the first major paper that I wrote. so that was one of the reasons, to pick that paper. We showed that, newborns who were uninsured when much more likely to have adverse, health outcomes, compared to newborns who were insured. and we showed that the Medi-Cal, which is the California Medicaid, Medi-Cal covered newborns were somewhere in between the uninsured and the privately insured in terms of their outcomes. We did that paper using, what had been used almost entirely as administrative data up to that point. Statewide hospital discharge data in the state of California. And I think to that point where there definitely was a movement at that time to.

[00:15:50] universal health insurance. There were a lot of people around the country who were striving for that, but at that point, my perception was that primarily that it was the bad guys who had the data and, all the good guys had when push came to shove was the feelings, the righteousness, and were real severe, disadvantage, there just wasn’t much hard data around on a lot of people were saying those who wanted to, justify the status quo would say at that point, it had been revealed that there were a lot of people who were uninsured.

[00:16:32] Paula Braveman: So, it’s that base had been covered, but there really weren’t hard data tying, being uninsured to, bad health outcomes. And the defenders of the status quo would say, oh yes, there are a lot of uninsured people, but the safety nets are there, they’re being taken care of, by charity care by, community health centers. So there’s really no problem. So, this paper actually probably made the biggest splash of any paper I’ve ever written. and. Huge, press, because it was saying, no, that’s not true. This is drawing blood, the lack of health insurance is tied two adverse outcomes.

[00:17:19] Thomas LaVeist: So just for the audience, this is a paper in new England journal of medicine, 1989. And I think it’s also, I think for, especially for younger people who grew up and lived in a world with prenatal care, that it really wasn’t until the mid-sixties with the perinatal collaborative study that we started to get really high-quality research that documented that prenatal care actually made a difference. So while today that finding from your paper, it may not sound like it’s, earth shattering. It actually was for the time. Ya know, people didn’t know this hadn’t acknowledged that, or hadn’t been documented that, medical care did make a difference.

[00:17:59] Paula Braveman: I think that was, what made the splash.

[00:18:01] Thomas LaVeist: but then later in your career, you seem to move away from the healthcare system as the place for the intervention. And I know that, your later work focuses a lot more on, the academics side of this kind of defining and conceptualizing, concepts like health, equity, health, disparities, structural racism, what these terms mean.

[00:18:21] Thomas LaVeist: Tell me about that, how that transition occurs as someone who’s trained as a physician, starting out doing work on, prenatal care and its impact to someone who’s really broadened far beyond the medical care system.

[00:18:36] Paula Braveman: After I completed a residency in family medicine at the local county hospital, I got what at that time was my dream job, which was working in one of the original office of economic opportunity, funded, health centers, in San Francisco, and working as a physician there, I quickly came to the conclusion that. Most of my patients, the issue wasn’t so much the medical care, but the conditions in which they were living and the stressors, that they were experiencing. And I don’t think I articulated that, but I think I was feeling that and feeling some, limitations of what I could do as a physician.

[00:19:24] Paula Braveman I worked as the Dr. Ash, a local house high school, the only high school in San Francisco that had a, a school-based health center and, working with, adolescents was always my favorite, the most fun, but there to what these kids were up against, at home, in their lives outside of school, seemed so much more daunting in a way. but I still, I persevered in my research I persevered looking at, essentially disparities in healthcare. Over the nineties. Literature was accumulating, calling into question just, prenatal care as a panacea or, for birth outcomes. And that, that was shaking me up. I think that that literature and at the same time, more attention was being given to the concept of the social determinants of health and by social, what people have referred to it they’re really meaning social, but not medical care, outside of those factors, outside of medical care, that influence health, and that literature made so much sense to me.

[00:20:44] and said by these experiences, both the experiences as a physician and then as a researcher with looking at birth outcomes, that I made the leap and I was lucky enough to have a sabbatical. It was the one sabbatical I ever managed to take. And I spent a lot of time that sabbatical, just trying to get up to speed and the literature on the social determinants of health and I felt like a fish in water in that literature.

[00:21:22] Thomas LaVeist: that was certainly a productive sabbatical, because you went from reading that literature to helping to define a lot of what we mean by some of these terms. So in the nineties,  you know, and well really starting in the eighties and into the nineties, We didn’t even really have good terminology to talk about this problem, but I know that, some of your work really helped to frame what the terminology was, for example, defining health equity as the terminology, which we now use, as we talk about this issue, as opposed to health disparities or back in the eighties, it was just race differences in health was how we were talking about. So, what was your thinking there about why you decided to start doing that kind of work, defining these concepts and helping to create a foundation for the field?

[00:22:00] Paula Braveman: there is a very discreet, event that I would point to its responsible for me going in that direction and that was that. A couple of very influential people who were at a major organization, came out with this notion that they had developed a much better way to think about and measure health inequalities.

[00:22:31] Paula Braveman: There were a couple of people in, leadership positions in a prominent international organization and they were both very bright. and they presented a paper at a meeting. I wasn’t there, but I heard about it in which they were proposing a different way of measuring and thinking about health inequalities. The term used everywhere except in the US. So, we, say health disparities and health inequality. and the approach that they were, suggesting had a lot of lure to it because, ya know it’s very difficult to get health data that are appropriately dis-aggregated by markers of, people’s level of social advantage, by race or ethnic group by, social class. Often, we lack the data sources to do that and what they were saying that we’re just going to measure health of Everyone. And then ya know How big are the differences in health

[00:23:40] Thomas LaVeist: You mean the distribution across the population?

[00:23:42] Paula Braveman: Yes

[00:23:44] Thomas LaVeist: not least healthy from the most unhealthy and what’s that gap.

[00:23:48] Paula Braveman: Exactly. And it would’ve made life a lot easier as to adopt that. but there was just one little problem, which was that it entirely removed the social justice content of the concept. And, initially I tried to poke holes in what they were doing from a technical point of view, but at a certain point, I realized this isn’t about technical issue, that what they are proposing, it’s removing the social justice content out of these concepts, which were introduced in order to look at, that we need to, We, when I said we, that people who care about social justice and, that people who care about social justice need to, take this on head on and directly and talk about values and talk about the fact that what they’re proposing, does not answer the questions that we have.

[00:24:50] Our questions are about social justice and about who is faring well and who is fairing ill, with comparisons by people’s level of social advantage. so that really is what turned me in this direction. I think if that hadn’t happened that, proposal by those influential people, I don’t know that I would have invested as much time as I have, and continue to invest, specifically in trying to, promote clarity about what we mean when we say health equity.

[00:25:29] Thomas LaVeist: So carrying this theme forward around promoting clarity. So, I noticed an article that you published this year in health affairs, ya know talking about, systemic racism, structural racism, trying to clarify these concepts and differentiate among them. Say a little bit about that paper and.kind of what ,What you were trying to do with this one. 

[00:25:53] Paula Braveman: that paper represents an attempt by me to reach out to a broader audience than the audience that I think is generally reading about. and hearing talks about issues like structural racism and systemic racism. It represented an attempt to speak to a wider audience, wider, but not, widest we might say, I mean that health affairs, the readership there, I think the appeal there read by a lot of policymakers who are not reading the health literature. So, it wasn’t an attempt to try to be as clear as possible and get the jargon out of the way.

[00:26:40] Thomas LaVeist: So, I think this is an important point here that I want to stress, especially for younger scholars who are coming up, that the three papers we’ve talked about, the first one on, prenatal care and pregnancy outcomes was interlinked with medicine. Um the paper and for those listening to the podcasts, we will post, the citations to these papers on the webpage. So you’ll be able to get to them you want to read them. the second one was American Journal of Public Health, 2011, where you had talked about defining health equity, defining the terminology and beginning to create the lexicon that we use now, as we talk about these issues and this latest paper is health affairs.

[00:27:19] it seems if I’m reading you that there’s a theme here where you select journals, not based on just, Hey, I think they’re published here, but rather who’s the audience that I’m trying to reach. So, talk a little bit about that, but how you try to link your message to the audience and how, ya know the importance of doing that, as opposed to just writing an article and just submitting it to a journal.

[00:27:43] Paula Braveman:   I became a researcher, out of a desire to contribute something, to struggles for social justice. It wasn’t just the fascination with research, although I’m very lucky. I love doing research. that wasn’t a sacrifice at all. but I think might have found other things like being philosophy professor, that were gratifying. but I think what you know was central but, feeling like I’m contributing some little thing. And I’ve never thought that any one individual, generally can accomplish very much, whether we have any influence at all, probably depends a lot on what so many other people were doing and whether things converge and there are a number of us doing things that are mutually reinforcing, but, anyhow, I saw my niche doing the research that would get into the policy debates and contribute to, more.

[00:28:47] Paula Braveman: Justice oriented ethos. so, I think it just follows from that, I had to look at the audience. For some papers, I’ve had more choice than others. it’s not all papers that are even going to stand a chance with certain journals. but within the realm of what, might be a, a fit might be a possible fit, it would always make sense to me to choose the most, influential. also say that in this vein, we’re the last, how many years? 14 years. maybe I’ve, worked with, a, the Robert Wood Johnson Foundation, um, on producing materials, a series of issue briefs that reach out to a way broader audience than any academic journal,  and that’s been profoundly satisfying and, and it has helped me, and, , I think, working on the issue briefs and having the input of people who, Have some communication skills, which people like us are never trained to, to do, to, to have. I think that has helped somewhat, even in the writing that I’ve done for more, academic journals.

[00:30:01] Thomas LaVeist: So I’d like to, close out, with this, So to the next generation of researchers,  what wisdom would you impart to the next generation of researchers? where do we take off from where we are now and how do we build going forward and, uh, and continue to move us towards this equitable society that we, that we’ve been working on for the last few decades?

[00:30:19] Paula Braveman: I would appeal to the next generation of researchers to focus on really important questions, including questions that, have implications, strong implications for social justice that, ya know it has  become in the last 10 years or so. I think there’s been a big shift in the acceptability of research, that does, incorporate, a social justice perspective. I know that you’re, you’re, you are younger than I am, but I think you’re still of a generation that where I mean, talk about somebody who is published, uh, studies that, , are important for, for struggles, for social justice. That’s certainly you and I would bet that even though you are younger than I am for much of your career, so far you, you had to have the guts to do that because it wasn’t going to get you ahead.

[00:31:24] Paula Braveman: And in fact, it was gonna get you, suspect as somebody who couldn’t be a good scientist because you’re motivated by, by values. but I think during this last 10 years, there has been a transition and this, the newer generation does have it easier than we have had it. I don’t think it takes much courage for them to focus on these, tough questions and the comparisons of the haves and the have nots and the exploration, how to, understand the disparities and what needs to be done about them.  it’s not as hard, at least for right now. We’ll see what, you know, there could be you know, another sharp turn  and it could  then, you know, again, become more like the situation that you and I have faced where you, you do have to, accept the fact that some people are going to, they’re not gonna be pleased. at the research questions that you’ve, that you’ve chosen.

[00:32:22] Thomas LaVeist: Yeah. Well, Paula. Thanks so much for this great conversation. And as always, it’s a pleasure talking with you and thank you also to our listeners. We hope that you found this engaging and we look forward to having you tune in for the next episode.

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