Dr. Anita Ravi, President, CEO and Founder of PurpLE Health Foundation, shares how the organization provides free, trauma-informed health and mental health care to children and adults affected by violence, including human trafficking and sexual assault. PurpLE Health Foundation also uses data to identify best practices and trains other providers to better care for populations facing threats and barriers to optimal health.
Please note, this conversation includes sensitive topics that some listeners may find upsetting.
Guest: Anita Ravi, MD, MPH, MSHP, FAAFP, President, CEO and Founder, PurpLE Health Foundation
Host/Producer: Carol Vassar
TRANSCRIPT
Announcer:
Welcome to Well Beyond Medicine, the world’s top-ranked children’s health podcast produced by Nemours Children’s Health. Subscribe on any platform at nemouriswellbeyond.org or find us on YouTube.
Carol Vassar, podcast host/producer:
Each week, we’ll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar. And now that you’re here, let’s go.
MUSIC:
Let’s go, oh, oh, well beyond medicine.
Carol Vassar, podcast host/producer:
In 2015, a medical resident named Anita Ravi volunteered time with women incarcerated at the Rose M. Singer Center, part of the infamous Rikers Island Jail Complex in New York City. What she saw and learned there shocked her. But instead of just walking away with lessons learned, Dr. Ravi did something. She started the PurpLE Health Foundation, which centers on helping survivors of gender-based violence, including women and girls who have experienced human trafficking, domestic violence, and sexual assault.
Many of these women and girls continue to face enormous challenges. Homelessness, incarceration, unemployment, safety concerns, single parenthood, and of course, concerns regarding their health. Primary care physician, Dr. Anita Ravi, joined me to talk about this work. And a warning, we will speak frankly about these topics, which can be triggering. Let’s begin our conversation as Dr. Ravi recalls those trips to Rikers Island, what she saw, what she learned, and what inspired her to act. Here’s Dr. Anita Ravi.
Anita Ravi, Founder, President, and CEO, PurpLE Health Foundation:
So, as you said, back in 2015, I continued with a tradition that I had started when I was a family medicine resident, which was volunteering on Rikers Island in the women’s jail as a health educator. And basically, having the opportunity to hear questions that people had and then being able to look up answers, come back the following week, and just help people understand basic things like what is a pap smear, things that they had noticed in their health, like what is thyroid disease and things like that. And I noticed when I was doing this work, sometimes once a month on Mondays, the public defender’s office used to come into the jail and they would do a know your rights type of workshop. And it was around human trafficking. And what they would do is they would educate women who were incarcerated about human trafficking. And let them know that some people who may actually be survivors and they may not even recognize it, which was something that I had no idea about.
In the past, a lot of my work has been around working with incarcerated survivors of domestic violence. There’s just a huge proportion of survivors who are incarcerated, particularly among women. And so, when I would sit here watching these workshops, I had no idea that there were trafficking survivors who were incarcerated. So, I started a research study where I had the opportunity to collaborate with trafficking survivors who were incarcerated. And interviewing them and asking them about their healthcare experience while they were being trafficked. And asking them what would make them feel more comfortable in general connecting with healthcare, either during the trafficking experience or maybe even years out.
And that study happened back in July 2015. And basically, it burst forward this idea of creating an actual clinic that could meet the needs of what survivors said would make them feel comfortable connecting with essential care. So, that’s really how a lot of things started. It started from survivor voices and the community orgs that support them as well.
Carol Vassar, podcast host/producer:
Now, as you were listening to survivors, it sounds like one of the things that they weren’t able to do was connect with the system to get the care they needed; is that true?
Anita Ravi, Founder, President, and CEO, PurpLE Health Foundation:
Yeah. People connected in different ways, actually. So, sometimes it would be through the emergency room. I think one of the most important things in doing this care is recognizing that you don’t always need to know whether someone has experienced trauma or is a survivor in order to deliver them excellent healthcare. So, a lot of times people were saying they had actually doctors and clinicians that they really trusted, that they would go to, but that the clinician had no idea that they were a survivor. And that it was okay, because it was going to take time to build that relationship. And in the meanwhile, there was something that that clinician was communicating, that made them feel comfortable, still being able to say what they needed and getting the care that they deserved. So, there’s a lot of different paths for survivors to connect with care. I think our job as clinicians is making sure that we leave as many doors open as possible and create the ones that need to be created as well.
Carol Vassar, podcast host/producer:
I do want to ask this: what did you discover when you first started going to Rikers, and then, as you’ve been doing this work for 10 years now, are there some of the unique healthcare-related challenges faced by survivors of sex trafficking or even other kinds of abuse?
Anita Ravi, Founder, President, and CEO, PurpLE Health Foundation:
After I wrapped up the research study, I piloted a clinic. It was called PurpLE Clinic. It was PurpLE Health Foundation 1.0 in the early days. And it was nested inside of a larger community health center in New York City. And I think one of the most important things in this work is really level setting and understanding what happens in medical education around things like human trafficking, intimate partner violence, and sexual assault. So, typically, we are trained to be able to screen for whether violence is occurring and asking questions like “Are you safe at home” or things like that. And then the culture is to screen. And if people say yes, to then refer them to social services. And I think for so long, issues around gender-based violence have been thought of as a social problem that shows up in a clinical setting.
And I think what I started to notice in doing this work and being a primary care physician for survivors, and seeing people six months after a violent relationship or exiting, or 15 years after they’ve had the experience, but they were nervous about getting healthcare in between, is you start to notice misdiagnoses of health conditions that people come in with. And you start to notice patterns in other diagnoses. So, what I started to notice was things like there’s a higher tendency for my patients to have some form of an autoimmune condition, whether it’s something like lupus or something else that has an inflammatory-related pathology. And I think what has been interesting, sometimes in the gynecologic part, you’ll notice survivors may have a higher incidence of endometriosis or polycystic ovarian syndrome.
And so, I think recognizing that there’s a larger piece to this, beyond kind of screening. And referring and recognizing that healthcare has a role in really managing the healthcare and medicine of survivors is really important, and it’s a huge gap. So, I feel like our work has inadvertently become creating a field of medicine, which is really gender-based violence healthcare. And looking at how do you thoughtfully and competently care for someone throughout their life span, so that they get the care they deserve and can live the life that they’ve been dreaming of.
Carol Vassar, podcast host/producer:
Clearly, there’s a need for this. What have you found with regard to how this has grown in New York City into PurpLE Health Foundation from a clinic, and writ large across the nation? It sounds like there’s a definite need for this kind of care.
Anita Ravi, Founder, President, and CEO, PurpLE Health Foundation:
One of the toughest parts of my job, I think I naively in the very beginning thought when people say things like people need access to healthcare, that’s true. But that’s only part of the truth. People actually need access to competent healthcare. And there’s a big difference in that. Just opening a door and being like, “Okay. You came in, let’s give you your blood pressure medicine. Let’s take care of all of these things.” But not recognizing that the ways people communicate, they may or may not be comfortable in sharing the full scope of what’s happening. And you having the skills both to be able to engage people, and to make diagnoses, and understand in a care plan that people can actually access and utilize is important. So, I say that because I think one of the toughest parts of my job is recognizing that there is a need for competent clinicians in this work across the country.
There’s a statistic that one in three women experiences some form of gender-based violence. So, basically, everyone knows someone, whether they realize it or not, who is a survivor. But hardly anyone knows someone who can deliver care for survivors. And I think I see that all the time, because our organization receives referrals from across the country, from community-based organizations that say, “We’re taking care of survivors here in Seattle or here in Texas, or here in Ohio. And we were wondering if there’s someone that you would recommend that we could see for medical care.” And there’s amazing clinicians across the country that do it.
But I think what’s needed is kind of a collective effort. Not just individual unicorns in a healthcare system, but a system-wide buy-in and a cultural buy-in, in the culture of healthcare and medicine, that this is an invisible population that deserves to have high standards of healthcare and is getting missed otherwise.
Carol Vassar, podcast host/producer:
Would you say that’s a failure of medical education in any way?
Anita Ravi, Founder, President, and CEO, PurpLE Health Foundation:
I don’t know if failure is the right word, because sometimes I try to follow the thread all the way through and get the root cause of what is causing this. We don’t invest in understanding, is particularly in women’s health. And so, I think of the population that I serve. So, I often liken it to the VA or veterans. So, in veteran care, when we think about post-traumatic stress disorder or PTSD, we think of war. And veterans have an entire healthcare system, and they also have programs that are thoughtful around it, like court intervention programs. There’s housing programs, there’s work integration programs. But when I talk to my patients… So, I say this because I was actually… when I was building PurpLE, I was also a clinician at the VA in the women’s health clinic there. So, I was kind of doing this work in parallel.
And what I noticed with the patients that I was serving in PurpLE is they’re veterans of an invisible war. There’s no one else sometimes that can attest to the war that they’ve been through, but they’re always reintegrating from the experience that they had. And sometimes people are able to physically leave a war behind, maybe across an ocean. But the thing that’s really hard for the population we serve is sometimes the people who perpetrate are still in the ecosystem for patients. It’s not post-traumatic stress disorder of its continuous exposure.
And I think that that’s really important, because once you start to frame it as things like from a healthcare lens, then you start to understand how do we invest in what we’re seeing. How do we listen to people differently to see if there’s a diagnosis or more research that needs to be done? And then it trickles down into medical education, and what counts, and what is deserving of the time and space for clinicians to be educated on something that’s important.
Carol Vassar, podcast host/producer:
A lot of moving parts there, but important parts that need to come together. I want to talk a little bit about the relationship between trauma, health, and poverty. Talk about the intersection of this particular triad and how it affects survivorship and recovery for those you serve, for those you care for.
Anita Ravi, Founder, Presiden,t and CEO, PurpLE Health Foundation:
Thank you for bringing that up, because I think so often in this work, people, they’ll be like, “Well, that’s not really in healthcare’s lane.” When we first started PurpLE Health Foundation, one of the key pillars we wanted was physical health, mental health, but also financial healthcare. And what we mean by that is this concept called the health poverty trap. And so, what that means is the cycle of where people who experience poverty may have decreased access to healthcare. If they have employment, because they’re sick, it’s harder for them to get sick days off. And so, then they lose their job and they stay stuck in this cycle. Trauma, and especially things like domestic violence, make that cycle even worse. It becomes a downward spiral and not even a cycle.
And so, what you see sometimes in the perpetration of whether it’s trafficking or domestic violence, is parts of financial abuse where a lot of survivors may not have their own bank accounts. They don’t have a credit history. They have a lot of bad debt, either because of something an abuser did or they were never allowed to control their finances. That becomes incredibly important when you are a doctor, sitting there looking at a patient. And let’s say someone needs to refill two medications, that they’ve run out of their lupus meds, and they’re also having headaches, and we need to do something else about it.
I think now, especially with the advent of payless transactions and credit card, there’s so much assumption that people have access to online credit, that people have access to credit cards. People can easily pay for and access the plans that we come up with. And I think what we’ve found in our work is often it’s hard for people to actually have the means and the infrastructure in place to execute just picking up a medication, having transportation to a visit, basic things, because the finances that need to be in order or the way in which the financial transactions have to be there aren’t in place for certain parts of our population.
And then the other part, too, is employment is extraordinarily hard. When you’re dealing with both PTSD and then the constant risk of more trauma, it becomes really hard to manage all that with your mental health care, and having time off work, and time for childcare, and being able to prioritize your health. To think about it when you schedule follow-up visits for your patients. When you think about can this patient actually do a telehealth visit, is it safe for them to do it at home? But can they afford to actually come in? So, these are small, but I think that these are system opportunities for us to design more thoughtfully around a population that we’ve forced to adapt into how we do care by default right now.
Carol Vassar, podcast host/producer:
You’ve listed a number of barriers. You’re calling them opportunities. I’m curious how the foundation works with the communities, in the organizations that are in the community, because obviously you’re not doing this in a silo, to ensure that the programs that you’re putting up, standing up to address the specific needs of those you serve are actually effective in making sure those barriers can be overcome.
Anita Ravi, Founder, President, and CEO, PurpLE Health Foundation:
Again, I appreciate this question so much, because it does break open this concept. It’s not just one siloed org sitting here doing this thing that’s just off the grid somewhere. It’s all based on connection, and we survive from connection and we thrive from connection. So, what we do at PurpLE Health Foundation is we think of this work in basically how do you build a field. And the way that we are building a field… So, we have an affiliated medical practice called PurpLE Family Health, and that’s where we do free medical care for survivors. So, my co-founder is a therapist. She and I work together. I do the primary care. She does specialized trauma therapy. And it’s basically doing trauma-informed care for survivors. We don’t use insurance. It’s completely philanthropy and grant-based. And that way the only primary stakeholder is our patient.
We don’t have to ask questions for reimbursement purposes. We ask them because they’re relevant to someone’s care. All of that happened because of our community partners and because of feedback from patients. Probably in the New York City area, we’re connected with at least 75 different community-based orgs. Most of our referrals come from community-based partners who do the social work or the legal aspect of things. And then some of our referrals come from patients. The experience worked for them, and so they felt comfortable telling other survivors, “Oh.” That’s one part of our work. And then typically, what we do is we gather together everything we learn from clinic. The clinic is almost a laboratory for understanding what does and doesn’t work for best practices. And then we’re able to study that. And then the other big arm of our work is actually clinician training. So, we’ve probably trained about 10,000 clinicians across the country in all different specialties, in working with GBV survivors.
And the coolest part of this is we recently piloted a program where we worked with medical students. And we were able to hire lived-experience educators. Survivors that we work with were hired as consultants. We were able to pay them awesome hourly rate. They co-designed a curriculum. They taught at least 100 medical students from across the country on Zooms, on their expertise of navigating the healthcare system as survivors of trauma. And it’s awesome because that’s really impacting things upstream. We don’t do this work just… it’s not a hierarchy-based thing. It’s a team-based thing. And I just love that, because I just think we’re building a field together.
How many people can say that they contributed to creating a field in healthcare? But this is the only way we’re going to do it, because it’s been a blind spot for so long. So, it takes people who are in the system, people who’ve been formally trained in it, like me, people who’ve experienced the system, and the people who are continuing to come up, all of those pipelines. So, I don’t know. Surrounded by hope in community is the only way that I like to think through what’s happening here. And I think it’s really important, and I wish it wasn’t needed. But this is the best way to address it.
Carol Vassar, podcast host/producer:
It sounds like it’s part and parcel of the success of the work that you’re doing, all of the community connections, and also having the survivors, those with lived experience, being part of the process. Is there someone with lived experience who sticks out in your mind, who kind of helps you to get up in the morning and say, “I am going to do this again today?”
Anita Ravi, Founder, President and CEO, PurpLE Health Foundation:
Well, so it appears at different times in life. But I do really want to mention my incredible colleague, Keisha Walcott. So, it’s actually the three of us. Jessica Gorelick is my counterpart in the therapy world. And Keisha Walcott, she was my former patient. So, she was one of PurpLE’s first patients about 10 years ago, and now she’s my colleague. And it’s really awesome, because she’s our lived experience care navigator for the clinic, but she’s also the director of our Lived Experience Advisory and Research Network program. It’s been incredible for us to be able to real time work together, learn and understand the landscape of what is happening and how things are changing. And so, she’s one of several incredible people that I think of often.
One question that comes up often, that I always… People are like, “Oh, the work is so sad. How do you stay positive so much?” or things like that. But I actually feel it the other way because of the work and because of the people that I get to work with and the people who trust us to trust them back. And Keisha to me is one of those people. And we have survivors on our advisory board, in our board, and in all sorts of other places, that help me know that we’re moving forward with a purpose that’s doing right by the people that we work with.
Carol Vassar, podcast host/producer:
And it’s important to have those with lived experience be part of the process. Talk about the importance.
Anita Ravi, Founder, President, and CEO, PurpLE Health Foundation:
Yes. That’s where it’s, I think, going above… It’s not just, oh, let me put out a survey and get some opinions or otherwise, from people who’ve had the experience. Honestly, I think of myself as a placeholder. I think of myself as someone who have maybe created scaffolding for the clinic structure and maybe for a field. But it’s really to be able to create a pipeline so people can come up in the future. Whether it’s a survivor who goes on to medical school or goes on in healthcare, or medical students who are working right now who can do better by family members, or other people that they have. But I just think that it’s not a us or them, or survivors and patients, or doctors and patients, or this and that, that’s just all false. Everywhere we go, whether it’s in the news or otherwise, we’re constantly interacting with people whose journeys I think we respect in different ways. And you respect it by building something that shows that you see someone. And I think that is what the experience of this is in whatever experience people show up with in this work.
Carol Vassar, podcast host/producer:
You’re an incredibly positive person. And I’m going to ask you a tough question. What are the challenges you faced or are facing as you advance the mission of PurpLE health?
Anita Ravi, Founder, President, and CEO, PurpLE Health Foundation:
I think of this on two levels. I think that there is a large understanding or there’s a lot of unlearning to be done, I think. I think there’s still a lot of reflexes in healthcare or otherwise that just, again, still see gender-based violence or this is almost an inconvenient social problem, and that we should stay in our lane with how it’s managed. I mean, I think what’s been really interesting right now in how we’ve designed the infrastructure for having a clinic, and a training program, and doing research among that is… When it comes to funding, I think philanthropy doesn’t fully understand the complexity of the healthcare system. And I think the healthcare system doesn’t always fully understand a nuanced difference between what they may feel is an appropriate band-aid to a situation like a free clinic with volunteer clinicians that’ll work on the weekends. And that’ll “cut down costs.”
And you cannot design thoughtful systems in that way. Our patients, they need to know what to expect. That’s such a key part of trauma-informed systems is predictability. And if they have to keep repeating their story, if they don’t know that the clinician that they saw one day is going to be the same one that they’ll see next week, or they have to keep waiting for access to care, that’s not a just system. But I think right now, people kind of think like, “Oh, yes, the solution is X and we don’t need to think beyond that.” And I think a lot of our job is to push that and to challenge that narrative and to say, could we design something that’s beyond the current imagination, both in the healthcare sphere and in philanthropy as well?
Carol Vassar, podcast host/producer:
I’m really fascinated by the healthcare that you’re providing, that side of the house of what PurpLE Health Foundation does. In the course of your work, have you been able to take some of the lessons learned and create evidence-based practices to be incorporated to care for your patients, not only locally in New York, but in other areas, you’ve been able to get it spread across the nation or even across the world?
Anita Ravi, Founder, President, and CEO, PurpLE Health Foundation:
Yeah. So, actually, I have a background in public health and in health policy research. And I think that’s awesome, but it can also inadvertently be a barrier when you’re working with certain populations. And what I mean by that is I think sometimes in medicine or statistics, we just, again, immediately default to what is a gold standard in evidence. It has to be a randomized control trial and it has to have X number of patients for something to be “valid.” And you start to wonder what is valid with the people that I see. If I see one person who’s experienced some barrier in care, how do I know in a difficult to reach population, whether they’re actually representing 50 or if they should be ignored because they’re just one?
And I think in the beginning, I was looking at this and I was like, okay, well, I’m just going to document what I see. And then I didn’t expect it, but a lot of people actually came to me and to PurpLE to be trained. And I was worried, because I was like, oh, my God, how do I know if this is evidence-based? All I have is the clinical experience that I am doing this work in. And what I realized, when you’re actually starting something, is you don’t start off in a clinical trial. There’s years of anecdotal data. There’s so many things that count, and that you have to be aware of. And you have to honor that they deserve to count, in order to actually get to the point where we can meet the criteria of what other people determine to be valid.
So, one example of that, I’m a primary care clinician, and sometimes I was noticing, I was seeing some of my patients at PurpLE who would say that they would have difficulty swallowing. And if you look at the American Family Physician Journal guideline, they a big review a few years ago on… the clinical term is dysphagia for difficulty swallowing. And the review had all these other things that could cause that. And one of the things they put is acid reflux disease. And this is how clinicians work it up and that kind of thing. What I started to notice is the survivors who mentioned this also had histories of strangulation, and having histories where they were being choked as part of the violence that they experienced.
Unfortunately, there’s an International Strangulation Best Practices Society. I mean, this is something that people in forensics get trained in, because it comes up in sexual assault, it comes up in all of these other places. But we’re not connecting those dots between what we know to immediately happen and the long-term consequences of it. So, when I started to notice it in clinic, I started to dig back and I started to change how I asked my history. And what I noticed when this journal article came out is my colleague and I wrote a letter to the editor saying, “Hey, what about strangulation as a cause?” Because it actually changes the diagnosis. Instead of sending someone to a gastroenterologist, GI doctor, you might send them to an ear, nose, throat doctor for further evaluation.
And so, the letter was accepted and it was published. And to me, that is a form of scaling what you see in clinic as evidence. And those are tiny pieces of how you start to put together a field of what counts and what doesn’t. And again, there’s so many systems out there and so many other fields that we can learn from. I think of myself as someone who’s connecting the dots across fields. And that helps accelerate progress and knowledge, hopefully globally, as you said.
Carol Vassar, podcast host/producer:
And that’s important work to be doing?
Anita Ravi, Founder, President, and CEO, PurpLE Health Foundation:
Yes.
Carol Vassar, podcast host/producer:
What’s the future for the PurpLE Health Foundation? Where would you like to be in a year, five years, 10 years?
Anita Ravi, Founder, President, and CEO, PurpLE Health Foundation:
Oh, as I said, I think when I do this work to me, I will never feel enough to do it because it’s going to fix the immediate problems that I’m seeing. I don’t want to be a part of it, if I can’t think about how what I’m doing now will ever lead to prevention in the first place. The ideal goal and in the future would be you never need clinics like this, because we’ve learned better and done better. And we’ve stopped hurting each other in ways that other people are comfortable with, frankly, or that we’re able to look away from. And I used to ask myself, am I doing enough in the prevention aspect with the work that I’m doing? And I hold myself and PurpLE accountable to that.
And so, I think actually a big step towards prevention of this type of violence in the future is actually naming it now, establishing a field, giving it credibility, and then you have the opportunity to build connection and learn from people. And then it’s valid by more and more people. And I think that’s how actually we generate the best solutions to stop the cycle. And so, I hope at least even a year or five years from now, that we’re creating a certification program for gender-based violence care. And there can be more clinicians who I know they’re already reaching out, seeking this out. But I know they can be unicorns in their system, and we can normalize being competent in this. And I think that is a first step towards hopefully eradication and prevention in the future.
Carol Vassar, podcast host/producer:
I couldn’t put it any better myself. Dr. Anita Ravi from the PurpLE Health Foundation, thank you so much for enlightening us.
Anita Ravi, Founder, President, and CEO, PurpLE Health Foundation:
Thanks for giving this opportunity to share about this work. This is how change happens. Thank you.
MUSIC:
Well Beyond Medicine.
Carol Vassar, podcast host/producer:
This is how change happens: learning about it and acting on it. Thanks to the amazing Dr. Anita Ravi from the PurpLE Health Foundation for being a beacon of light and hope to so many. It’s been a privilege to share her story. We’re always looking for stories that go well beyond medicine. Perhaps you know of one. We do want to hear about it. Email us at [email protected] or leave a voicemail on our website, nemourswellbeyond.org. That’s nemourswellbeyond.org, where you’ll also find past episodes, which are also available on your favorite podcast app and on the Nemours YouTube channel. Our production team today includes Susan Masucci, Cheryl Munn, Lauren Teta, and Steve Savino. Join us next time as we explore the advantages of remote mental health services for children and adolescents. I’m Carol Vassar. Until then, remember, we can change children’s health for good well beyond medicine.
MUSIC:
Let’s go, oh, oh, well beyond medicine.
