Dr. Faith Fletcher Of The Baylor College Of Medicine: In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System
An Interview With Luke Kervin
Strengthen the public health infrastructure. Public health is the science of protecting and improving the health and well-being of individuals and communities. Public health professionals try to prevent problems from happening or recurring by educating the public, advocating for policy implementation or changes, implementing surveillance systems, delivering health care services, and conducting research. We also work to balance individual autonomy and interests with the ethical obligation to protect the public’s health. The COVID-19 pandemic is a public health crisis that has revealed that we must strengthen all aspects of our public health infrastructure to improve the health of the nation.
The COVID-19 Pandemic taught all of us many things. One of the sectors that the pandemic put a spotlight on was the healthcare industry. The pandemic showed the resilience of the US healthcare system, but it also pointed out some important areas in need of improvement.
In our interview series called “In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System”, we are interviewing doctors, hospital administrators, nursing home administrators, and healthcare leaders who can share lessons they learned from the pandemic about how we need to improve the US Healthcare System.
As a part of this series, I had the pleasure to interview Dr. Faith Fletcher.
Faith Fletcher, PhD, MA, is an Assistant Professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine and a senior advisor to the Hastings Center, a leading bioethics research institute. Nationally, Dr. Fletcher is contributing to critical conversations around health equity, structural racism, medical mistrust, and anti-racism in bioethics. She has been featured in Huffington Post, National Public Radio, Science Magazine, and Rolling Stone. In 2017, Dr. Fletcher was named one of the National Minority Quality Forum’s 40 under 40 Leaders in Health for her commitment to improving access to scientific research and quality health care for medically underserved populations. This prestigious award acknowledges the next generation of leaders primed to reduce health disparities.
Thank you so much for joining us in this interview series! Before we dive into our interview, our readers would like to get to know you a bit. Can you tell us a bit about your backstory and a bit about what brought you to this specific career path?
I was drawn to a career in public health and bioethics early in my academic training as an undergraduate student engaged in programmatic activities through Tuskegee University’s National Center for Bioethics in Research and Health Care — one of the first bioethics centers in the nation to focus on issues related to health inequities, racial justice, minority health, and public health. I was inspired to pursue a career in health disparities research examining and critiquing the role of existing structural forces that perpetuate poor health and health care among medically underserved populations. To prepare for this career, I completed graduate-level training in bioethics and public health and postdoctoral training in behavioral science at the University of Texas MD Anderson Cancer Center, as well as a research ethics training fellowship at Fordham University’s HIV and Drug Abuse Prevention Research Ethics Training Institute. As a social and behavioral scientist, I work with various collaborators, stakeholders, and communities to examine and address health and health care inequities that are deemed avoidable, preventable, and unjust. I also teach health behavior change and health equity courses to future public health professionals and health care providers.
Can you share the most interesting story that happened to you since you began your career?
Solving complex and persistent health inequities requires a multi-faceted approach and various forms of expertise, from the expertise of the individuals who reside within a community to that of the local leaders and other public health experts. Discussions with various experts took on particular importance over the past two years, as we tried to identify and overcome myths and misinformation about COVID-19 in African American communities, in particular. At the beginning of the pandemic, I worked with colleagues to develop and lead virtual town halls to educate African American communities about COVID-19 health inequities and address the influx of misinformation. Audience members expressed an appreciation for town halls that featured trusted and respected leaders who disseminated accurate information. As the African proverb tells us “If you want to go fast, go alone. If you want to go far, go together”. In short, we can achieve health equity nationwide through collective efforts in consultation and partnership with various experts, community leaders and residents by engaging in respectful and transparent processes. Much of my work over the past decade underscores the importance of multiple perspectives and disciplinary lenses to develop innovative health solutions to ameliorate health inequities.
Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?
I’m not sure I would categorize this as the funniest mistake I made, but in hindsight, it may be one of the most informative mistakes I’ve made. Near the end of my PhD program, I applied for a health disparities postdoctoral fellowship. I was invited to interview and spent weeks preparing. This interview was unique from others that I encountered because we interacted and engaged with the other applicants for several days. During this time, I noticed that I was one of the few applicants that had not been trained at a “top tier” public health institution. Despite my strong training from field leaders with firsthand experience in the issues we strive to resolve, I immediately felt out of place and started to feel like a major imposter. In the first of several interviews, the interviewer asked me: Who did you train under? Do you feel like your training in public health was adequate? Does your institution lead clinical trials? Despite knowing that my training was far more than adequate, I left the interview feeling demoralized and frazzled, and as a result I misread the schedule and missed the subsequent interview. Missing my postdoctoral interview was a huge mistake, but second guessing my training and my worth was my biggest mistake. As a burgeoning scholar, I spent many years asking myself: Should I be here? Am I an imposter? Do I belong? As a nation, we must reckon with the many ways that structural racism, classism and bias can lead to systematic marginalization, stigmatization, and ultimately exclusion in many settings. As a faculty member and advocate for diversity, equity, and inclusion, I am actively engaged in collaborative initiatives to inform equitable practices that mitigate bias and discrimination in application processes for students, staff, postdoctoral fellows, and faculty.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
The founder of Tuskegee Institute (now known as Tuskegee University), Dr. Booker T. Washington, reminds us that “success always leaves footprints”. As a Tuskegee University alumna and social justice advocate, “leaving a footprint” is a legacy that I work to uphold and is central to my leadership philosophy. I am who I am today because of the elders, mentors, and scholars who labored and sacrificed to make the world more equitable, more diverse, and more inclusive. I view my work as a piece of — and connection to — a much larger collective and vision for social justice, and I strive to leave footprints that lead future generations to forge unprecedented paths.
Are you working on any cool projects? How do you think that will help people?
One new project that I am working on is funded through the National Institutes of Health Mentored Research Scientist Development K01 Award to work with community partners and other stakeholders to develop ethical practices and guidelines for engaging medically underserved populations in genomics research. In this work, I am focusing on individuals in the rural South who are vulnerable to numerous health problems because of multiple factors, including extreme chronic poverty, limited health care infrastructure and access, and an unfriendly built environment. Many of these factors also discourage participation in the research studies that could ultimately improve prevention, treatment, and care options. My goal is to establish ethical frameworks and guidelines that reflect the unique values, preferences and priorities of these individuals and thus increase their participation in the research necessary to provide them with equitable health care.
How would you define an “excellent healthcare provider”?
As a researcher who studies health care experiences and engagement from the patient perspective, my body of work highlights the importance of a provider who listens to the patient’s concerns, prioritizes their preferences, and understands their lived experiences. I can also speak to health care engagement on a personal level. I recently moved back to Houston, Texas, and the past several months have consisted of navigating Houston’s health care system. Through my personal networks, I discovered Black Doctor Locator and Houston’s Black Doctors. These resources helped me to identify gender and racial concordant health care providers to meet my health care needs. The primary and specialty care that I have received so far has been patient-centered, respectful, and effective. Instead of disregarding my professional training in public health and ethics (as I have experienced with other providers), my providers have leveraged my insight and expertise to optimize my health care. While provider-patient concordance has been identified as an important approach to reduce health inequities, I don’t attribute the quality care delivered by my Black female health care providers to being merely a product of our shared racial and gender attributes. In my opinion, these providers are excellent providers because they approach the clinical encounter with the spirit of humility, collaboration, and respect for different types of personhood. Much more empirical work is needed with both patients and health care providers to understand how providers can deliver excellent and tailored care to all patients. We should learn from the excellent providers that are leading the way in this area!
Ok, thank you for that. Let’s now jump to the main focus of our interview. The COVID-19 pandemic has put intense pressure on the American healthcare system. Some healthcare systems were at a complete loss as to how to handle this crisis. Can you share with our readers a few examples of where we’ve seen the U.S. healthcare system struggle? How do you think we can correct these specific issues moving forward?
The health care system struggles with acknowledging its historic and ongoing role in systematically imposing harm on communities of color and other marginalized groups. Further, those most affected by health care system injustices are often characterized as distrustful, hard-to-reach, non-compliant, risky, and more recently vaccine hesitant. To truly address health care system harms and inequities, we must dismantle those narratives, frameworks, and practices that make individuals and communities responsible for the moral failures of the US health care system. During the pandemic, I was featured with other colleagues in a Rolling Stone article written by Dr. Elizabeth Yuko, titled “Why Are Black Communities Being Singled Out as Vaccine Hesitant?”. This well-circulated article centered various expert perspectives, including a health care provider, faith-based leader, community stakeholder, and two public health scientists. Here, we argued that positioning vaccine distrust as a problem specific to African Americans is not only inaccurate and unjust — it’s also harmful. The US is morally and ethically responsible for rebuilding a health care system rooted in trustworthiness and equity.
Of course the story was not entirely negative. Healthcare professionals were true heroes on the front lines of the crisis. The COVID vaccines are saving millions of lives. Can you share a few ways that our healthcare system really did well? If you can, please share a story or example.
In the face of rapidly spreading and far reaching misinformation about COVID-19 and vaccines, health care providers and health care leaders continue to serve as vital and reliable sources of information for many patients and the general public. Committed to health justice, many continue to use their various platforms to address vaccine concerns and misinformation through tailored messaging, and, thereby, influence behavior change among the unvaccinated.
Here is the primary question of our discussion. As a healthcare leader can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
- Strengthen the public health infrastructure. Public health is the science of protecting and improving the health and well-being of individuals and communities. Public health professionals try to prevent problems from happening or recurring by educating the public, advocating for policy implementation or changes, implementing surveillance systems, delivering health care services, and conducting research. We also work to balance individual autonomy and interests with the ethical obligation to protect the public’s health. The COVID-19 pandemic is a public health crisis that has revealed that we must strengthen all aspects of our public health infrastructure to improve the health of the nation.
- Address the social determinants of health. Where a person lives, learns, works, plays, and ages profoundly shapes and influences their health. Social determinants of health or non-medical factors like reliable transportation, affordable and quality housing, and employment all significantly contribute to health outcomes. Effectively addressing the social determinants of health to improve the delivery of health care calls for collaborating with partners from various sectors to inform innovative solutions.
- Confront racism in health care. The Centers for Disease Control and Prevention (CDC) recently declared racism a serious threat to the public’s health. In fact, it’s racism, not race, that’s a primary driver of the social determinants of health. Racism in health care settings limits access to quality care for patients of color. Well-documented research has revealed unjust differences in health outcomes between racial and ethnic groups, and a specific focus on anti-Black racism in health care is urgently needed.
- Acknowledge and address the public’s concerns. Acknowledging and addressing concerns raised by members of the public — especially in communities that have been socially and medically disenfranchised — is key to rebuilding trust in the health care system. Engaging people to understand their needs, realities and lived experiences is necessary for a comprehensive health care delivery approach.
- Engage trusted community leaders. In light of the influx of information and the inherent difficulty in identifying reliable sources of information, it is important to engage trusted sources to disseminate evidence-based information to communities. The need to engage a range of trusted community leaders to help fight the COVID-19 pandemic has been apparent from the beginning to many of us working in public health, as we witnessed misinformation about the virus spread rapidly. To improve the health care system, we must build alliances and partnerships with people outside of health care like faith-based leaders, barbers, and stylists — those trusted leaders that are rooted in the communities most affected by health inequities.
Let’s zoom in on this a bit deeper. How do you think we can address the problem of physician shortages?
The Association of American Medical Colleges (AAMC) among other organizations, identifies physician shortages as a growing health problem. There are multiple ways to address this shortage, including strengthening the US public health infrastructure. However, as the COVID-19 pandemic has revealed, a lack of engagement in preventive behaviors like mask wearing, social distancing, and vaccine uptake to prevent the onset of disease and death can produce or exacerbate a physician shortage. A well-cited parable that many public health professors present in their introductory public health courses is the story of a man and a woman who are attempting to fish but instead end up spending their entire afternoon rescuing people who fall into the river at an upstream location. Eventually, they grew tired of rescuing people and travel upstream to figure out where and why the people are falling in. They discover that people are drawn to the edge of the cliff to look at the river, placing them at risk of falling in. To prevent the need to continuously rescue those who fall in, the fisherfolk work with the local community to build a fence at the edge of the cliff. As the story demonstrates, “investing upstream in prevention rather than downstream in intervention is often wiser and more effective and is the essence of public health”. Downstream intervention is costly, and requires more resources, including more physicians to address preventable health conditions. We need to adopt a focus on “upstream thinking”, including more effective public health education, public health campaigns, public health surveillance, and policy and systems-level change to increase engagement in preventive behaviors, to ultimately keep people from falling into the river of illness and thereby aid in addressing the physician shortage.
How do you think we can address the issue of physician diversity?
Addressing physician diversity is a priority highlighted in the American Medical Association’s plan to advance health equity. From my experience teaching health equity and health behavior courses to undergraduate and graduate students, including aspiring physicians, it’s important to address the current structures and policies that advantage some students and disadvantage others in the application process. For example, many students that are underrepresented in medicine may not have access to resources or programs that increase the likelihood of medical school acceptance, such as competitive summer internship programs (which are sometimes unpaid and require housing), Medical College Admission Test (MCAT) preparation courses, mentoring in the art of writing strong personal statements and requesting winning letters of recommendation, and the funding necessary to apply to multiple medical schools. Improving physician diversity requires dismantling the embedded racist and classist structures that prevent the same opportunities of success for all students that aspire to become physicians.
How do you think we can address the issue of physician burnout?
As a public health researcher and bioethicist, I believe we need to conduct empirical research with physicians to identify better ways to measure, define and address physician burnout, as suggested by recent studies. The COVID-19 pandemic has also underscored the need for ethics infrastructure for health care providers and the general public, which are both currently navigating uncertainty and complex health and medical decisions. Making ethicists available in both health care and community settings and offering clear ethical guidelines for such health and medical responses may aid in addressing the ethical dilemmas and moral distress that are experienced by health care providers and result in burnout.
What concrete steps would have to be done to actually manifest all of the changes you mentioned? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
Improving the overall health and well-being of the public requires targeting individuals, systems, and political structures that profoundly shape health outcomes. Understanding complex and persistent health problems and their determinants is strengthened through multiple nuanced perspectives and disciplinary lenses. Cross-disciplinary collaboration between health care providers, public health professionals, bioethicists, social workers, and other professionals allows individuals with diverse training and experiences to come together to address a common goal. Furthermore, collaboration provides the opportunity to build alliances and partnerships across professions and with communities to develop meaningful and sustainable strategies to improve the health of individuals, communities, and society at large. In short, transforming the health care system calls for systematic engagement, dialogue, and collaboration among various stakeholders to develop innovative health care solutions.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)
I experienced a traumatic life event several years ago and sought out mental health resources. Because of the stigma associated with mental health therapy, I was not comfortable accessing the services available to me at my place of employment. Although I identified several mental health providers who could provide the specific care I needed, each was out of network or did not accept health insurance. In the absence of formalized mental health services, I relied on my personal network of family and friends with various forms of expertise (i.e., pastors, health care providers, mental health providers, and lived experiences) to help me through something that couldn’t be cured with my inner “resilience”, strength”, and/or “grit”. I often wonder how the outcome would have been different without my strong network of resources. We need to revolutionize health care by developing innovative models of health care that address the holistic needs of patients and mitigate the stigma and shame related to accessing any type of health service (including sexual and reproductive health and mental health services). As health professionals, we need to advocate for comprehensive and integrated health services that are accessible, affordable, and acceptable to improve the health of and health care for all. Finally, if the pandemic has taught us anything, as health leaders, we have a moral and professional obligation to take a more active stance against racism — a serious threat to the public’s health.
How can our readers further follow your work online?
Follow me at www.faithfletcher.com and @FaithEFletcher via Twitter. You can also view the “5 Things We Must Do To Improve the US Health Care System” video here: Dr. Faith Fletcher — 5 Things to Improve the U.S. Healthcare System — YouTube
Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.
