Fighting Healthcare Disparities | Supporting the Refugee Community

Paul Anderson: Welcome to Smart Healthcare Safety from ECRI. The most trusted voice in health care committed to advancing effective evidence- based care. I'm your host, Paul Anderson. And for more than 10 years, I've overseen our patient safety risk and quality membership programs here at ECRI. Tens of thousands healthcare leaders rely on us as an independent trusted authority to improve the safety, quality and cost effectiveness of care across all healthcare settings worldwide. You can learn more about our unique capabilities to improve outcomes www.ecri.org. Today's episode is part of a series we're recording for the ECRI and the ISMP Patient Safety Organization's deep dive report. This year's deep dive focuses on issues of racial and ethnic disparities in care. And we're talking to PSO members and others to hear about their initiatives to fight against these disparities. Our guest today is from Valleywise Health's refugee women's health clinic located in Maricopa County, the area around Phoenix, Arizona, which has served more than 9000 refugees from more than 60 countries since 2008. The refugee women's health clinic has a long established infrastructure of community partnership, engagement, and shared community leadership that through collaboration facilitate and coordinate culturally competent care, services and support. So, to get us started, I'll ask our guest to introduce herself.

Thank you so much, Paul. I'm happy to be here. My name is Dr. Crista Johnson- Agbakwu. I am an obstetrician gynecologist and the founding director of the refugee women's health clinic at Valleywise Health. I also have an academic appointment at Arizona State University in the Southwest Interdisciplinary Research Center. And basically, my work is seamlessly integrated between clinical care, health services research, which are both embedded within the community. And it forms kind of like a trifecta in terms of really advancing health equity for vulnerable populations, namely, the large and growing refugee population here in Arizona. Or I'll probably add one other part is that we also are very much embedded in teaching and training the next generation of clinicians and scholars. And Valleywise Health is the largest public safety net and public teaching hospital in the State of Arizona. So that's also a very important framework for the work that we do.

Paul Anderson: Let's talk a little bit more about that framework. So I mentioned that you're in Maricopa County, which I guess includes Phoenix and is also very around Phoenix, is that right?

Crista Johnson-Agbakwu: Exactly. Yes.

Paul Anderson: Can you tell me a little bit more about the refugee community that you serve?

Crista Johnson-Agbakwu: Sure.

Paul Anderson: And in particular, for today's conversation, what are some of those barriers that we see to help them?

Crista Johnson-Agbakwu: Absolutely. So, many may not be aware that Arizona has a long standing history of refugee resettlement, dating back to 1975. And so, we have resettled upwards of 82,000 refugee new arrivals. These are migrants whose first foot in the United States is in the State of Arizona. And of course, that doesn't necessarily reflect secondary migration to and from other states. But yes, we've consistently ranked in the top 10 US states. In fact, our peak was back in 2016, when we settled upwards of 5000 new arrivals. And we are anticipating, with the current refugee admissions cap established by Congress in the Biden administration. If the United States agrees to resettle 125,000 new arrivals, Arizona is designated to get anywhere between 7000 to 9000 new arrivals, which is quite substantial and the highest that we've ever received in history. And so clearly, we are at the front lines of really serving an emergent need of a very vulnerable population that have survived human rights atrocities and war and conflict and are establishing their lives here in the state. And at Valleywise Health we've addressed that head on for the past 13 years. We were founded in 2008. And we have become a best practice model, not only for the state, but for the nation in terms of looking at unique ways that we have sought to address health equity and really build very strong and deep partnerships with our various refugee community stakeholders.

Paul Anderson: One of the things that I think has really come out, not only in learning about Valleywise, but learning about a lot of different organizations that work in a lot of different spaces around the country is it's never just about literal clinical health care, right? That's a piece of it. But it also involves a lot of community education, community engagement involvement. Can you describe some of that sort of community education and involvement that the refugee women's clinic is involved in and leads.

Crista Johnson-Agbakwu: Absolutely. So one of the first things we put in place when we started this clinic was developing a community advisory coalition. The actual formal name is the Refugee Women's Health Community Advisory Coalition. It is a coalition that is comprised of over 60 stakeholders that are all serving the refugee community in various ways. For instance, we have close partnership with the public health department, the state refugee resettlement program office, area resettlement agencies, such as Catholic charities and IRC, which is the International Rescue Committee. We have very close partnership with ethnic community based organizations that reflect the various refugee communities that we are serving. And just to give the audience an example, we have served, since we started, populations from across Sub Saharan Africa, Southeast Asia, and the Middle East. Our largest populations arriving now are coming from the Democratic Republic of Congo, from Iraq, from Burma or Myanmar, from Somalia. And now, with the recent Afghanistan evacuation, we are slated to receive in the coming months upwards anywhere from 1000 to 3000 new Afghan arrivals as well. And we're preparing for that surge. And so, as you rightly state, beyond just clinical care, we really need to nurture very strong engagement with the community. And through our coalition, we've been able to do that. And because we've been in place for over 13 years now, we have very strong, deep and trusted roots within and across our community. And that is so critical when we think about especially in the era that we've been in and continue to be in with this pandemic. Trust is absolutely critical. And so, we've been able to nurture and sustain trust as we seek to build the capacity of our communities to be responsive to the emerging needs of a very highly vulnerable population. In addition to our coalition, the other most critical aspect of what we've done from the very beginning is that we have built in an integrated, what we call, cultural health navigators. It's pretty similar to what we are more familiar with, like the Pomodoro model, or community health workers more broadly. It's very similar to that. But what's unique is that these are women and men who are trusted leaders within their respective community. They are certified medical interpreters. They speak upwards of 18 languages, and some individuals themselves speak six to eight languages individually, much less across our entire team of men and women. And they have that cultural knowledge. They have that shared lived experience of force displacement. They themselves are migrants coming from the same exact regions of the world that we also serve, from which our patients are from. And so that is tremendous, because that builds a critical bridge linking our communities, our families, and children and our patients directly to our health services. And so, honestly, when I talk about all the work that we do, it would not be possible without this team. They are able to bridge that critical gap, enhance literacy, facilitate care coordination and case management, and really fill that gap in terms of meeting the needs of the patients wherever they might be in a safe way, creating a safe space, a trusted safe space. And, really, I'm hoping to facilitate clear navigation that optimizes their health outcomes. And that's something that we have been doing for many years. But only recently, we've begun to really track some of those outcomes. And we've really seen the profound impact this has had on improving quality outcomes for women. And I must also add that because we have started with women's health care, we have grown since then, because we've delivered well over 2000 newborn babies. We know that refugee families escaping conflict also come with their family, with children. And so the pediatric refugee clinic has exploded with children who are also receiving services, in addition to serving the extended family, including men. And this has all been directly connected to our coalition. Our community have been at the forefront and at the table hoping to drive our priorities. When we realized that we were not serving men adequately, we learned that from our community partners. They said, " You're doing an excellent job serving women and children. But what about men? We're left that we need care too." And so that's a perfect example of how we have leaned in and leaned on that critical voice of the community to help drive and prioritize where we should be focusing our efforts. And as we now look at this Afghan concern regarding the very large number of evacuees, we are doing the same exact thing really leaning in to our community network and our partners to help us better coalesce our care operations and our communications to really prioritize the needs of this very vulnerable population that's now arriving on our doorstep. And what is so critical is the fact that we anchor this in really educating the community, communicating effectively and using innovative strategies. Especially given this COVID pandemic, that we might not necessarily be able to go door to door knocking on doors in the neighborhoods as we did before the pandemic, but we're heavily relying on other forms of messaging, leaning in on social media and other elements to really make sure that we are communicating effectively with our community, with our patients and their families, and most importantly, enhancing their health literacy too.

Paul Anderson: So let's pull on that thread a little bit, because I think this is all related. One of the things that always really interests me is this combination of the sort of the individual community relationships and the voice of the people in the community sort of married with data, right, because we can look at that sort of big picture and hear the anecdotal which can point us to a big picture we want to pull on a little bit. So, I mean, just as you were listing off the different countries where you have families and individuals from, right, you've got Africa, Southeast Asia, the Middle East, you've got all over the globe. What kinds of data are you then gathering about your community, about your outcomes, whatever the situation is, that then marries with, as I said, that sort of individual and group outreach to sort of help shape where you're going to turn next.

Crista Johnson-Agbakwu: Sure. So, I could probably give you two separate examples of that. One related to how we are advancing health equity around women's health and the other, very timely, related to this pandemic. So, let's see, let me start with how we've advanced health equity. So, over the past few years, for many years now, we have very strong partnerships with Mercy Care, which is a Medicaid health plan that ensures the lion's share of our patient population. And it so happened that over the years, Mercy Care has delved into looking at their claims data and examined how they're doing across all of the claimants that they insure. And they found some of the unique trends that were happening in the refugee population at Valleywise. And that, when we look at this subgroup, somehow they're performing really well. We're looking at data on birth outcomes, C section rates, emergency room use, hospital admission and readmission rates, lose quality metrics that are followed very closely nationally in terms of looking at maternal and child health outcomes. And so they noticed that we were actually doing better than their general pool of claimants. And so, they thought to really examine this more closely. And they put in place a pilot initiative where they were setting aside some funds to fund our cultural health navigator specifically to help them hone in on the maternal child health initiatives that we were already embarking on. But now, we're able to formally track this very closely. And so with this pilot in place, we were able to actually demonstrate clearly improved outcomes by looking over a specific designated time period and we had some baseline data before the time period started so we can compare. And indeed, we found that in our patient population, we actually were showing improvement on many quality metrics relating to maternal child health in terms of birth outcomes, in terms of initiation of early prenatal care, in terms of hospital emergency room use, hospital readmission rates. Indeed, it was proven correct, that we're surely achieving quality outcomes that are far better than the general population and even compared to our own baseline metrics. And this has resulted in several tens of thousands of dollars in cost savings. And so this is really radicalizing how we think about maternity care financing. Especially with this pandemic, there's been heightened attention to innovative methods of improving quality care and reducing costs, especially in vulnerable populations disproportionately impacted by the COVID 19 pandemic. And so, that's one perfect example of where we have excelled tremendously. And we are indeed a model for replication in other fields, like pediatrics and family medicine, potentially across other Medicaid health plans. Value based care is getting a tremendous attention these days in terms of how we can truly achieve improved health equity for particularly high risk populations. The other example, I wanted to give you that directly use data to completely transform public health response is how we responded to this COVID-19 pandemic. And so, we are a public safety net hospital and that being said, we disproportionately serve vulnerable populations, migrants, underinsured, uninsured patients. And so, when we think about the impact of COVID 19 and its disproportionate burden on vulnerable populations, we are the poster child of that, so to speak. But that is also an opportunity for us to really showcase the tremendous work that we're doing. And so in the early months of the pandemic, when we saw that Arizona was being hit very hard with high rates of COVID 19 infection, we were one of the first hospitals to put in place universal mask wearing. And I attribute that to the leadership of Dr. Michael White that really put us in the front line and really addressing how we, as a health system, were responding to this crisis. And what we're able to do is on our labor and delivery unit, we instituted universal testing immediately on our labor and delivery unit. No other hospital was doing that at that time. And instantly, within the first few weeks, we saw that we clearly had a problem on our hands. Because just in a few weeks of testing, we found that there was a disproportionate burden affecting our refugee population. We recently published that in the past year. Essentially, the discrepancy was 27% of refugees were testing positive compared to only 3% of our general population. And when you look over the entire course of the few months of when we're capturing this data, it maintained, that that disparity was substantial, and that it was approximately close to 18% of our refugees were positive compared to about 8% of our general population. And we know because this is a vulnerable population we're serving anyway, we found that when we did antibody testing that the general prevalence of those who actually just had COVID antibodies was around 34%. So, you can see the kind of population that we're working with. But you know, we were the canary in the coal mine. Because we took that data, we took that live emerging data, and directly notified our public health colleagues at Maricopa County Department of Public Health. We said, " Hey, we have a crisis, we clearly see in these initial weeks that clearly, the burden is substantial for our refugee population and what can we do to address that." So that's how we directly use data to really inform public health, which because they were then able to form at the county level, a COVID 19 refugee outreach unit, where they realized that they needed to put boots on the ground. Using our similar model of cultural health navigators, they were able to hire a team. They hired five community health navigators, they termed the phrase, to basically be boots on the ground to really get into these neighborhoods and really target these neighborhoods to make sure that they were advancing public health information and outreach to make sure that they were addressing some of the issues with inability to social distance because they're living in cramped multi- generational households. Often refugee families of nine were crammed into a two bedroom apartment, things like that. And as you can imagine, these are opportunity for a serious community spread. And of course, we know in the refugee community, there are serious communication and language barriers, limited health literacy, limited computer literacy. Remember, in the days of even with the vaccine rollout, you need to register to then get to a pod to get vaccinated. And that's a non- starter when you don't even read in English, nor know how to navigate a computer. So you can just imagine, contact tracing efforts were initially just in English and Spanish. So, how do you do this in Arabic and Swahili and Burmese, right? And so that's why it was so critical that we take a tailored approach to making sure that we are communicating effectively using trusted community members to really advance COVID 19 mitigation efforts. And that has been tremendous in terms of us using data to drive public health outreach and education in very targeted and vulnerable communities. Another thing that we did, as part of that effort, was to develop educational videos. Our team, our pediatric colleague, Dr. Michael Do was instrumental in really coalescing our team of navigators, who created videos in their respective languages across close to 10, 11, 12 languages that are now available on YouTube that had well over 200, 000 views. We had three series focused on COVID information, how to remain safe, social distancing, mask wearing. And finally, a third video series was just released specific to the vaccine and combating the misinformation around and that it's propagating vaccine hesitancy, as we are all very familiar with. But we use our own team members talking about their own experience getting the vaccine, and even having video footage showing them getting the vaccine, and that they are okay and how can we help to dispel some of those myths and provide factual information to help promote vaccine acceptance in these communities. So, those are just two examples that I wanted to share that shows how we are directly using data to drive public health response and public health outreach. And we need to do more of that to really make sure that we are targeting not only our clinical care, but our programmatic and community outreach and our research efforts that are tailored to the vulnerabilities specific to certain communities. It really requires a tailored and individualized response. I'd like to term this as precision public health or precision population health. And that's kind of the area that I'm chartering with my research efforts.

Paul Anderson: What's really interesting to me is that it hits at that intersection of you described earlier, health literacy, right, I've got just literal language barriers, I've got cultural competence issues, I've got sort of all these things balled into one. So my background, right, I'm an editor, so my whole world is written in paper and paragraphs. And I am personally, how do I want to say this, right, I don't watch a lot of videos. If I can avoid it, I will read before I watch. But it strikes me that these videos you're describing, they are sort of a great way to short circuit a lot of those challenges and get to, as you said earlier, I've got a native speaker who has shared life experiences, who can speak to community, both in language that they will understand, but also in speaking experiences that they understand. And that seems like just a great way to just do an end around all of the nonsense and get the information, as you said, fact based information right in the hands of people in a way that they can receive it.

Crista Johnson-Agbakwu: Absolutely. Absolutely.

Paul Anderson: Yeah. That's great. That's great. And as you said, a couple 100, 000 views taking into account what you mentioned earlier, folks who maybe don't have reliable internet access, right, but we can get the message to them if we put it out there in a consumable way.

Crista Johnson-Agbakwu: Absolutely. Yeah. And I think we are the perfect model of what should be done in other parts of the country and other populations, vulnerable populations, to really get at the core of what's driving a lot of the health inequities. And I think at the very core of this is really trust. Trust and human empathy, cultural humility. Those are nuggets that are often thought of as soft or fluffy and not necessarily crosstalk. Exactly. But this is absolutely critical to ensuring compliance with recommended treatment paradigms that you might not be familiar with, or might be scared, or you might not understand. But if you have a trusted person, who you identify with, who might share your cultural and linguistic background or heritage or lived experience that you can relate to. And they're saying, " You know, this is how this can help you," and distills that complex medical language in a way that is understood through the lens of culture and language and one's lived experience. I mean, you can move mountains. And I think the fact that we recognize that from the very beginning and nurtured that and built our entire system of operations around that foundational truth, I think, is what has set us apart from anyone else in terms of how we've been able to truly address that ever elusive health equity in terms of really improving care for entire populations.

Paul Anderson: I want to talk about trust for a second. One of the other themes that I've heard in a lot of these conversations that I've had is the folks who have been really successful, especially with navigating COVID, are folks who have had organizations built up in their communities over a decade, you said 13 years for the refugee women's health clinic, other places are similar lengths of time. We'll talk in a minute about sort of first steps from another organization starting from ground zero and I want to build up. How does an organization maybe that doesn't have that deep community engagement today, but they know they need to get there. So, how do they start to build up that trust to build up those relationships, because they know it's the key, but they're starting from scratch?

Crista Johnson-Agbakwu: This is at the core of so much if we could figure this out, right, we would make such huge leaps and bounds in terms of advancing health equity for vulnerable populations. I think, honestly, where we should start and what organizations should really think really carefully about is that representation matters. Often, these communities are often communities of color. And they have a history of historical human rights atrocities. Well, whether you're looking at Native Americans, whether you're looking at African Americans in the legacy of slavery, whether you're looking at migrant populations who have been displaced due to war and conflict and have experienced gender based violence and systemic rape, for instance, as a weapon of war. They've all experienced trauma, historical trauma, which creates pervasive distrust. And so, at the very core of how does an institution begin to build those relationships with these communities? You really have to nurture trust. And part of that has to do with representation, making sure that when you look at your organization, look around who at the level of leadership reflects the communities you're trying to reach. Who among research teams, among clinical care teams, among providers, who among them reflects the community you're trying to reach? Representation is absolutely critical to make sure that there's that authenticity, that commitment, that we're not just top down speaking to communities. We are making sure that they are part of our system of operations at every level, from the leadership all the way down to the healthcare worker working in various mundane services across the whole institution. And so, that representation is absolutely critical, because that brings important voice to how decisions are made that impact policy, that impact how care is delivered, how protocols are created. Being mindful of that voice, you need to have representation at the table where those decisions are being made that affect those communities. That is absolutely critical. And I think we need to land and sit on that for a minute. Because when you think about issues of implicit bias and the fact that we are now finally after well overdue, paying attention to the role of structural racism, as it shapes how we look at this, the disproportionate burden of health inequities on communities of color, and how that's informed by social determinants of health, of which structural racism is at the very foundation and core. These are very hard conversations and topics that create a lot of unease, as we've seen, over these recent years. But it's so critical for us to have and engage in those conversations. Because if we could really understand what's at the core, we would make such important gains in terms of how we are delivering programs and protocols and research paradigms that are informed by making sure that we have representation at the very table when those decisions are being made. And part of that also has to be recognition by institutions that we need to do a better job in terms of training our workforce, our healthcare workforce to be aware of the insidious nature of implicit bias and microaggressions that are part of the lived experience of living and breathing air in this country, because that's the historical legacy that we have and we cannot escape. But recognizing that and making sure that as we talk about health equity and as we just look at data, the ever importance of understanding data that we apply a racial equity lens to understand that as we look at our data, we're disaggregating it by race, by ethnicity, by language, by nativity, those are the things that often we stop at race and ethnicity and say, " Okay, we're done." But no, that's only part of it. Because when you think about refugees, refugees do not fall under those clear racial and ethnic categories of black, non- Hispanic, right? Like, what do you do if a woman is from Somalia. She is not really the same as a native born women, black woman, born in the United States, right, because their journeys, their migratory journeys and experiences are very different. But once they arrived in the United States, now that they are under the umbrella as a person of color, they now experience the effects of racism and discrimination and religious hostility if they are Muslim, for instance, that now add that weathering effect of chronic toxic stress that is now part of those social determinants of health that are impacting her experience or the family's experience and next generation who are now no longer migrants, but they're now US born but are, as communities of color, also experiencing the strain, the embodiment of racism and lifelong stressors and discrimination have on one's health. And so, I think, as we think about how health systems can move that dial forward, you have to make sure that at the very top all the way down, you have representation in leadership and in health services and care delivery that reflect the communities and that inform the way in which we design the programs and the way we track the data to make sure that it is with a racial equity lens. And how we train healthcare workers to be understanding of how implicit bias is really interwoven in everything that we do. And being mindful of that, so that we can catch it and be accountable to that in all that we do and how we train clinicians and how we engage in clinical trials, et cetera. So I think that would be the first big step to making sure that as we put programs in place, it's done being very mindful of our relationship with our communities and how we need to reflect that in all the work that we do and how we design the work from the very beginning.

Paul Anderson: You mentioned in the course of that talking about training, right, for our workforce, but in our prior conversation before we were recording that you also talked about the initial clinical education of caregivers, nurses, physicians, all sorts of all levels. So, I wonder if you could maybe sort of expand on that a little bit, and sort of the relationship between that sort of formative clinical education, and then as it sort of morphs into now I'm a person in my career and need that ongoing training and reminding.

Crista Johnson-Agbakwu: Absolutely. It's iterative. It's lifelong. I mean, we, as a physician, that's our mandate. Learning does not stop at the end of medical school or at the end of our residency, it's lifelong, because as you know, medicine changes. We learn more. Science increases. And so, it's imperative for us as we expand our knowledge, look how much we've learned about COVID 19. In the past 18 months, we never heard of this, this is a novel virus. But look at how our knowledge has exponentially exploded in the past 18 months. Look at the thousands of research articles that have been published helping us understand and unpack the impact of COVID. The same diligence is needed when we look at health equity. And we look at how we need to have an iterative framework in mind to think about as we evolve in our understanding and our knowledge of the impact of racism and social determinants of health, on health equity for vulnerable population, we need to continue expanding our understanding of how do we now use this knowledge to inform our approaches, working with communities of color. And so, it is absolutely imperative. In fact, as we think about just from the training standpoint, we must train the next generation of clinicians, of scholars, of nurses, of public health professionals. We need to make sure that as part of that training, they are gaining these critical skills at the same time that they're also learning core medicine or core nursing or public health skills and knowledge. They have to also, at the same time in parallel, understand the impact of social determinants of health and what is it naming it and making sure that they are very much attentive to how that not only influence the care that they provide, but how they think about themselves as individuals within those spaces, as they deliver care directly to patients and to communities. And so, it is absolutely critical to make sure that we think about this as an iterative process. That's why, hospital bodies have required mandatory training. We all have to do mandatory trainings throughout the year on being prepared or in case there's an active shooter. Understand if there's a fire, how to respond? These are trainings that we have that are also iterative. Every single year, I do the active shooter training because we see the gun violence is quite pervasive. The same way we treat these kinds of clear competencies, we need to apply those same iterative competencies to how we think about health equity and how we think about implicit bias and think about our care delivery to vulnerable populations. So, it is absolutely essential learning and iterative learning for all health care and public health workers in this space.

Paul Anderson: So, I think that leads us really nicely to sort of where I want to end up, which is the call to action that you published. I have it here. This was sort of late 2020, November 2020 that it was published. And you talked about in the call to action a multi- pronged coordinated approach, both by clinicians and public health professionals, to proactively and systematically advance health equity for Black Americans. So, obviously, that's a, to me, a very clear and very succinct. It is a call to action, quite literally. Could you describe, maybe a little bit more detail what you had in mind in that call to action and where you sort of see, if not next steps, next steps is a little cliche, but sort of where you see sort of that call to action needing to take root.

Crista Johnson-Agbakwu: Sure. Thank you so much for highlighting our team's collaborative paper. And so, we organized this around five key themes. And I could kind of highlight the five separately. But the five key themes was one, anti- racism, implicit bias and cultural competency training. The second one was capacity building. The third, community based participatory research engagement. The fourth, monitoring and evaluation. And the fifth, advocacy and empowerment. So these are all critical. One cannot exist without the other. They all have to be interwoven together and part of that comprehensive package in terms of how we can truly advance health equity. And so, I'll start with the first one, just to give some highlights. You've probably already heard me mentioned this already. But the importance of cultural competency training cannot be overstated. Because it involves not just institutional policies, but I think I want to really hone in on the fact that the onus is on us. We need to foster our own self- reflection to think about how we, as individuals, might be perpetuating stereotypes, or just approaches to how we might think about populations that might not coincide with our worldview or our lived experience, and really think about how we can take responsibility for how we might have our own biases and how that might influence the care that we deliver, or even how we think about drafting policy. And really making sure that it's more than our individual actions and the words coming out of our mouth, but also, how can we advocate for the next person. When we visualize and we witnessed this happening with other cure interactions, are we proactive in calling that out? So, it's more than just our own cultural competency, but it's also active like anti- racism to be able to call out and recognize when this is happening in other spaces that we might witness and making and calling that into account as well. And how can we do this is by making sure, again, representation matters that we bring people as part of our healthcare teams and our leadership teams that can help in driving that narrative and creating an inclusive environment. An environment of inclusive excellence, where every member of the team is valued and respected. And there are a lot of resources that have been developed by the AMA, the AMC and other professional entities that can help institutions gain that competency and have resources to provide that training to their staff. The second part is capacity building. And, again, how can we nurture say pipeline programs? When you think about physicians of color, we are highly underrepresented. So we need to make sure that if we don't see that representation around us, how can we nurture and build that over time? And that through supporting mentorship, pipeline programs, and proactively seek to make sure that we are seeking out to recruit faculty, residents, students of color, who can eventually grow into these positions of leadership and clinical care serving these communities. And we are not an island. We can work very closely with our community partners in helping to foster that workforce integration that builds in trusted members, such as cultural health navigators as a perfect example of how they can be integrated into as part of the fabric of our larger care team. So, that's how we can also enhance the capacity within communities too, working to very much address the very issues that communities face. And the third part is community based participatory research. So that is the critical anchor that has been at the bedrock of all of the research that I have done at ASU. Everything that I engage in, whether it's quantitative surveys, or focus groups or other types of research, it's really grounded in making sure that we are nurturing equitable partnerships with our community. And that how do you define community? I mean, that's very broad. It depends on your subject and topic of focus. But in my work, I have a community advisory coalition. I have worked closely with ethnic community based organizations, other community stakeholders serving the same population and make sure that they are at the table in terms of hoping shaping, not only research, but how we think about clinical care. We have such a very close knit partnership that we are coalescing around how we respond to the Afghan arrivals, Afghan evacuees. It demands community based engagement, because again, we are not an island. We are reliant on making sure that we are not missing any aspects of the multi- focal, multi- pronged approach that is so critical to making sure that these populations can be firmly established here in this country and have a pathway to economic self- sufficiency and health and wellness. The fourth part is the monitoring and evaluation. As I mentioned earlier, it's not enough to stop at just race and ethnicity in terms of how we disaggregate data. We need to make sure that the data that we're collecting has sufficient ethno- cultural specificity so that we can make sure we understand that whether it's country of origin or length of time in the US or language spoken, these are other critical elements that are so key to helping us be more precise in terms of how we think about how we collect the data and analyze and interpret the meaning of that data. And how can we follow these outcomes over time and develop quality metrics that are longitudinal to help us as we continue to be responsive to the needs of the population and make sure that we're putting in place proper measures that address quality care, the patient experience, for instance, and how we track morbidity and changes in outcomes specific to these very specific high risk populations. And lastly, and also very importantly, is continued advocacy and empowerment in terms of how do we not only nurture safe and inclusive environments for patients, but also, how we can be really respectful of amplifying the community voice, of making sure that we are inclusive of representing gender, linguistic congruence, cultural or racial congruence with our patients. How we can advocate and empower our patients to advocate for practices that will best support their health. And it might require innovative strategies, it might be something that hasn't been done before by the healthcare institution. Remember, we are dealing with populations that have limited health literacy. So, could we think of audio visual modalities or other ways that will empower communities that might not rely on just written fliers or written handouts that they cannot read because they haven't had the opportunity to go to school? So, I think, empowerment goes beyond elevating the patient's voice but also looking at innovative strategies that will meet the needs of the community in ways that are novel that might harness other modalities that we have not traditionally used before, such as using social media or hosting town halls or looking at other ways that policy can be informed by the data that we're collecting that is very specific for the unique populations that we are serving. Again, bringing in that code word, precision population health, precision public health, similar to precision medicine in genomic research. I think that is an important catchphrase that we need to start thinking about, because that really involves how do we educate, empower, create inclusive environments that will address health equity, but in a unique way that specifically targets the most vulnerable populations in the ways that would be most effective to improving health outcomes through all of the various areas that I've mentioned.

Paul Anderson: We've been thinking in terms of COVID in the last 18 months, but obviously, that's not been the only disrupter in that time. So, what's been the effect of the amplification during the same time of other social justice issues? And how do they all interact?

Crista Johnson-Agbakwu: I mean, I guess, the part of community embeddedness and advocacy should also consider social justice because I think that is something that the last 18 months, not only were we dealing with the COVID pandemic, we were also dealing with the heightened awareness of racism and its insidiousness and how that manifested with police brutality, how we now seeing that affecting women's reproductive rights, with the recent abortion ban in Texas. So, there's also major threats to health equity that are affecting vulnerable populations and communities of color in ways that we are seeing that are profoundly impacting these community's lives. And in addition to talking about how we can build capacity across institutions and being mindful of creating an environment that's inclusive, we also need to be very mindful of making sure that institutions are considering social justice as so critical to the populations that they're tasked to serve. Because it's all interwoven, and you cannot just pick and choose which topics you're going to say, " Okay, this one is good, I'll focus on this." You have to be holistic and think about all the different angles and ways in which communities live and breathe in this world. And we can't be myopic and only honing in on this clinical view where we have to fix their hemoglobin A1C, right? Because that can't be fixed if they are living in an unhealthy spaces and are dealing with stressors that profoundly impact their health and their ability to follow up for care or be compliant with treatment recommendations or be in the state of mind to focus on their health. We have to have that holistic lens. And part of that holistic lens has to be a lens that considers racial equity, considers social justice, considers social determinants of health and considers language and cultural congruent with care. So, I just think we really need to elevate the work that we're doing by considering this 360 degree view on the human being on the human person and really make sure that we can consider the cultural humility that's required to serve populations, especially populations that might not look like us or have our shared lived experience or worldview. And have that cultural humility recognizing that we all have the shared humanity. And humanizing medicine, humanizing public health and care, I think, will really go a far way to improving health equity because we ultimately have a global shared humanity. And respecting each other as fellow human beings, I think, is at the very core of how we can really make critical advances in health equity for the most vulnerable among us.

Paul Anderson: Dr. Johnson- Agbakwu, thank you for joining us today. Learn more about ECRI and the ISMP PSO from the ECRI website at www. ecri. org where you'll also find our 2021 Top 10 patient safety concerns report, which features racial and ethnic disparities in care as the top issue. You can find out more about Valleywise Health's refugee women's health clinic at valleywisehealth. org. Be sure to subscribe to Smart Healthcare Safety on Spotify, iTunes, Google Play, or wherever you get your podcasts to get our latest episodes and we welcome your feedback. Please visit us at ecri. org or email us at ecri- podcasts @ ecri. org.