Healing the World: Training Global Health Experts

reprinted from Issue 20, Spring 2015 of Frontiers of Medicine (PDF)

HEAL Initiative co-founders Phuoc Le, MD, MPH, DTM&H, (left) and Sriram Shamasunder, MD, DTM&H, (right) meet with Maxi Raymonville, MD, an OB/GYN at a Haitian hospital run by Partners in Health. For every trainee from a high-resource setting who is enrolled in the global health program, the HEAL Initiative also trains a health professional from a low-resource setting

Sriram Shamasunder (pronounced “SHREE-ram shah-mah-SOON-der”), MD, DTM&H, and Phuoc Le (pronounced “fook lay”), MD, MPH, DTM&H, met in Haiti in 2010 while volunteering after the devastating earthquake.

“We were amazed by the outpouring of support from health professionals who wanted to work in Haiti, but dismayed that people who had never worked in a resource-poor setting can end up doing more harm than good,” recalls Shamasunder.

“Having good will does not translate to having the expertise to do global health work,” says Le, noting that global health addresses health inequities in low-resource settings – whether internationally or within the US. “As physicians, we are at the very end of the line. We should go upstream to see what social, economic and structural factors led to disease, then provide mentorship in how to intervene as health care professionals.”

To build this kind of expertise, Le and Shamasunder co-founded the HEAL (Health, Equity, Action and Leadership) Initiative (healinitiative.org). The program builds on UCSF’s legacy of addressing health disparities wherever they occur, from caring for AIDS patients in the early 1980s, to pioneering new ways to prevent transmission of HIV, malaria and tuberculosis worldwide. Last fall, UCSF celebrated the 10-year anniversary of the founding of its Global Health Sciences (globalhealthsciences.ucsf.edu) program with an international symposium of global the new Global Health and Clinical Sciences Building on the Mission Bay campus.

Equity in Health and Education

Robin Tittle, MD, one of the first graduates of the HEAL Initiative program, uses ultrasound to care for a patient in Haiti as Phuoc Le, MD, MPH, DTM&H, looks on.

Starting in July, the HEAL Initiative will offer a two-year paid fellowship program in global health for physicians seeking both clinical skills and knowledge of how to strengthen health systems in partner-ship with communities, governments and nonprofits. For example, physicians are often unprepared to care for patients in environments without electricity or clean water, let alone X-rays, electronic medical records or lab tests.

“How do they provide outstanding care with a lot less?” asks Le. “We teach them to work with what they have.” Fellows learn to identify symptoms of common diseases through the physical exam and history-taking, and become skilled in analyzing blood samples under a microscope for common pathogens. They also receive rigorous ultrasound training, a technology which is more affordable and portable than X-rays and can be a powerful diagnostic tool. Fellows also learn how to connect with community resources and draw on successful models to improve health.

Every six months, fellows alternate between an international rotation at a partner site in Haiti, India, Liberia or Mexico, and a domestic rotation at one of the hospitals in the Navajo Nation in rural New Mexico or Arizona. (Please see related article on pages 4-5.)

All fellows earn a master’s degree in public health through UC Berkeley’s online program; tuition is covered by the HEAL Initiative. They receive ongoing support from field-based mentors, as well as site visits from UCSF faculty who fly out for one to two weeks during each rotation. Fellows also participate in a weekly videoconference with faculty and other fellows to discuss challenging cases and provide mutual support.

One of the HEAL Initiative’s cornerstones is equity. “For every person from a high-resource setting that we train, we provide that same opportunity to somebody from a resource-poor setting,” says Le. For each rotating fellow enrolled in the program, partner sites select a locally based health care professional – such as a Haitian pharmacist or Liberian nurse – who also becomes a HEAL Initiative fellow. These locally based fellows continue to work full-time at their jobs while receiving mentorship from UCSF faculty and field-based supervisors, participating in weekly videoconferences and earning MPH degrees from UC Berkeley.

“People from the [local] communities are extremely smart, and are the absolute experts in that community,” says Le. “To make real change, we need to provide them with tools and support, because they’re going to be the ones leading the way in improving their health care systems.”

“The HEAL Initiative is a necessary and innovative response to the global workforce shortage that is hampering the improvement of health for vulnerable populations in the US and abroad,” says Madhavi Dandu, MD, MPH, a HEAL Initiative faculty member who also directs UCSF’s Masters of Science in Global Health program. “With a focus on equity, the fellowship meets the demand of US trainees who seek post-graduate mentored training in global health delivery, while working hand-in-hand with health professionals based at partner sites who also receive mentorship and training.”

Global Health Bootcamp

To kick off the two-year fellowship, all fellows and faculty convene at UCSF for a monthlong global health bootcamp (globalhealthbootcamp.org), which provides intensive instruction in health system design, quality improvement, ethics and leadership training. Fellows learn hands-on skills such ultrasound training and take part in small group discussions. They also participate in ethics simulations in the state-of-the-art Kanbar Center for Simulation and Clinical Skills Education (meded.ucsf. edu/simulation) on the Parnassus campus. Fellows interact with professional actors who portray patients in difficult situations, debriefing with faculty and peers after each scenario.

With a point-and-shoot camera, Tittle captures a CT scan for a patient receiving treatment at a local hospital an hour away, which lacked the software to view these images. This is an example of an improvisation used to provide health care in a low-resource setting.

“Let’s say you’re faced with a patient whose spleen has ruptured, and they need surgery,” says Le. “You are a physician but not a surgeon, and the nearest hospital is 10 hours away. What do you do? We teach our fellows to consider all the key players and ramifications when making an important decision in a resource-poor setting, and that goes far beyond what we’re typically taught in medical school and residency.”

A four-day version of the bootcamp debuted last October, offered as a continuing medical education course to 36 health care professionals from all over the world. Participants in this minibootcamp found the concrete skills, exchange of ideas and relationshipbuilding useful.

“One key idea I will take home is collaborating with community health workers – those who do not have formal medical training – to help deliver health care services,” says Beatrice Kirubi, MD, a medical coordinator for Médecins Sans Frontières (Doctors Without Borders) in Kenya. “It offers treatment and jobs to the local community, and it’s something we should look at.”

“Most of us are not at an institution that has the resources, leadership, organizational skills and connections found on the UCSF campus,” says Angela Caffrey, MD, a gynecologic oncologist at West Michigan Cancer Center in Kalamazoo, MI, who volunteers at a Kenyan hospital. She found the historical overview of global health given by Joia Mukherjee, MD, MPH, a Harvard faculty member and chief medical officer for Partners in Health, especially valuable. “It was incredibly useful, succinct and memorable, and I really feel it should be a required talk for anyone entering a helping profession,” says Caffrey.

“If global health is a movement of people that are committed to international solidarity, the bootcamp started to do that by having Haitians and Ugandans and people from San Francisco and New York learn together,” says Shamasunder.

Justice and Medicine

Le and Shamasunder both have deep roots in global health. Le was born in Vietnam in 1976; when he was five, he fled to Hong Kong on a fishing boat with his family. He received virtually no health care until he emigrated to the US in the early 1980s. “Growing up, I heard stories from my mom that sparked in me a real interest in addressing these injustices in health care,” he says.

As an undergraduate, Le spent a year studying acupuncture in Beijing, witnessing health care disparities in an urban setting. While earning his master’s degree in public health from UC Berkeley, he spent months conducting research in Tibet. A graduate of Stanford Medical School, Le completed his residency in internal medicine, pediatrics and global health equity at Harvard Medical School, and cared for patients in rural Haiti, Malawi and Peru.

Shamasunder grew up in Southern California, the son of Indian immigrants. While an undergraduate at UC Berkeley, he took a poetry class from activist and writer June Jordan, who became his mentor. “She changed the way I thought about justice and people who don’t have the basics,” says Shamasunder. He remembers Jordan holding up a backpage photo in the New York Times of a flood that killed thousands of Bangladeshis. “She said, ‘If this was a bunch of Americans, it would be front page news! What kinds of people are valued less? Who gets sick, and why?’ Global health was a natural marriage of my interest in political activism and medicine.”

After completing his medical degree from New York Medical College and his residency at Harbor-UCLA, Shamasunder worked in several poor countries, including Burundi. “One of the hardest things to watch is a mother who trekked miles to the clinic, only to have her child die of something treatable like malnourishment,” he says. “You’d watch this mom strap a dead baby to her back to walk miles back home to bury that child. That was the first time I saw people dying from things we know how to treat, and it’s based on systems failures and not having a strong enough workforce. To be effective, I realized I needed other skills, like quality improvement and knowing how to mentor community health workers and create community alliances.”

Shamasunder and Le at UCSF Medical Center, visiting a patient awaiting a lung transplant.

Building on those longstanding alliances, in recent months Shamasunder, Le and other HEAL Initiative faculty have gone to West African countries affected by the Ebola epidemic, working with organizations such as Last Mile Health in Liberia, a HEAL Initiative partner. “The Ebola pandemic is helping people understand that building health systems everywhere is important to our own security,” says Shamasunder. “Ideally, all these doctors and nurses who are going to Liberia will take care of Ebola patients but also build the health system, so when the next virus comes down the pipeline, the system isn’t dependent on a bunch of Americans or Europeans.”

“Ebola is a symptom of a much more chronic problem,” says Le. “We need to tackle both this ongoing battle with Ebola, at the same time we work to improve the infrastructure and address the root causes of this disease.”

Sustainable Transformation

In addition to its visionary mission of promoting health and educational opportunities globally, the HEAL Initiative has an innovative business model. Each partner site invests in the project on a sliding scale. In return, partner sites get well-trained, closely mentored health care professionals who have made a two-year commitment to service. Also, by having their own staff members become HEAL Initiative fellows, they grow their own organizations’ expertise and leadership capacity. “Everybody has some skin in the game, which translates to accountability and long-term, true partnerships,” says Le. “It has to be win-win for everybody.”

The program has received generous initial philanthropic support, but Le and Shamasunder hope it will become financially self-sustaining in a few years. “We have built economies of scale into our financial model, so the cost of educating each fellow goes down the more fellows we recruit,” says Le.

A number of other potential partners have expressed interest in working with the HEAL Initiative, including organizations in Oakland, Nepal, Mali, and the Rikers Island jail system in New York. Le and Shamasunder hope to eventually have thousands of graduates who together will form a cadre of global health experts.

“These people will be leaders in settings across the world who will strengthen health systems and provide better access to health care for the poorest, most vulnerable populations,” says Le.

“The HEAL Initiative came out of deep reflection on our own experiences,” says Shamasunder. “This is the training program that Dr. Le and I would have liked to have done ourselves.” One inspiration is the Highlander Folk School in Tennessee, a leadership institute for Southern civil rights activists that trained Rosa Parks shortly before her act of civil disobedience sparked the Montgomery bus boycott in 1955. “We’re aspiring to build something like that in global health, where our graduates think about health differently for the rest of their lives,” he says. “We hope they learn ways of transforming themselves, the places they work and the patients they care for in a deep and meaningful way.”

HEAL Initiative’s Partner Organizations

  • Compañeros En Salud works to improve primary health care in the sierra of Chiapas, one of the poorest regions of Mexico.
  • Jan Swasthya Sahyog provides preventive and curative services in the tribal and rural areas of Bilaspur district of Chhattisgarh state in central India.
  • Last Mile Health, known in Liberia as Tiyatien Health, saves lives in the world’s most remote villages by recruiting, training and supervising talented community members to become professional community health workers.
  • Zanmi Lasante operates clinics and hospitals at 12 sites across Haiti’s Central Plateau and lower Artibonite, and is the largest nongovernment health care provider in Haiti. It is the flagship project of Partners in Health (pih.org)
  • The Indian Health Service, an agency within the US Department of Health and Human Services, is responsible for providing federal health services to American Indians and Alaska Natives.
  • The UC Berkeley School of Public Health offers an online master’s degree in public health program.

For more information about ways to support the HEAL Initiative, please contact Executive Director of Development Olivia Herbert at (415) 476-9878 or oherbert@support.ucsf.edu.

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