Sriram Shamasunder, M.D. is an associate professor of medicine at University of California, San Francisco. He is also co-founder and faculty director of the HEAL Initiative, a health equity organization that gives its fellows the opportunity to work alongside underserved populations in Navajo Nation and nine countries around the world.
Harvard Political Review: Let’s talk more broadly about your work in health equity. What are some of the pillars of HEAL’s curriculum that you seek to teach to your students or fellows? And how do you translate those ideas into practical knowledge for these eventual health-care professionals?
Sriram Shamasunder: Over the last five years, we’ve had 150 front-line health professionals come through HEAL in our two-year immersive program. Half of them are U.S. doctors or nurses. The other half are either Navajo or from countries such as Haiti, Mexico, Malawi, Rwanda, and India. One of our principles is for this incredibly diverse cohort of health professions to all come together and learn from each other. And so, as a young person, how do you apprentice yourself to people who are in closest proximity to suffering and immersing themselves in the real problems and challenges that communities face in healthcare? When you do that, I think the questions change, and there is what we call praxis, which is reflection in action. And so if you’re on the front lines, you’re immersed in the community and you’re seeing a lot of needless suffering and death. So when you reflect, the way you think about your work shifts and changes. And there’s no way to get that in a classroom; it means showing up and being in some of the communities. Whether it is in East Oakland or in Rwanda or in Navajo Nation, I think the principle of immersion is one of our core tenets.
We also teach about something called structural competencies – understanding how health outcomes are linked to structural causes of different populations or different patients. There’s a number of barriers and challenges. Being a good health professional requires a certain understanding of what patients’ lives are like and realizing the structural barriers for getting high-quality healthcare. And then we teach things around advocacy and leadership. We have these sessions on power and privilege, which is understanding with humility your positionality vis-a-vis the long history of a place. So, when I step into Navajo Nation, I better not think that I’m not part of an incredibly complex and integrated history. And in the role that I play, I should be aware of the long arc of history of Navajo Nation and understand the role that outsiders have played here historically. So that is one cornerstone that we focus on. I think when you have such a diverse cohort, you can actually have people teach one another. Because there’s such a breadth and depth of experience – you’ll have a Malawian doctor and a nurse from Navajo Nation and a pediatrician from Michigan all working together.
HPR: What difficulties do you have grappling with and integrating socioeconomic and political issues into practical healthcare work?
SS: Some of the difficulty is recognizing socioeconomic issues because oftentimes our medical training – our undergraduate training or medical training or residency – doesn’t give us the ability to understand the complex phenomenon that is behind patients. I think that when you start understanding these issues and reflecting upon them with your colleagues and your coworkers, then there’s an ability to say, “How do we shift this?” or “How do we change this?” For example, I think the county hospital in San Francisco was seeing that diabetics at the end of the month were having lower blood sugars because they ran out of food. Their money for the month had run out, and they would be using insulin, but they didn’t have the food so their sugars would run low. If you can recognize that problem and ask the right questions, then potentially you can change that with advocacy. And so that’s the goal. It’s not easy, it’s not quick, but it’s how you turn health professionals into “natural attorneys for the poor,” as [Rudolf] Virchow says. That’s what changes health and healthcare. We become advocates in a deep way for our patients.
HPR: Since you started working as a physician and in healthcare, what changes have you seen in terms of the salience of health equity among healthcare professionals specifically? And where is there room for improvement in that regard in the future?
SS: One thing that gives me a lot of encouragement is that young people are so clear on ways that health equity, inequality, and climate change – how all those things are linked to vulnerable populations and so intricately important in our own lives. I think when I started, there wasn’t the language around health equity, or health and human rights that is now part of global health conversations. Even the term “global health” was not in great use in the early 2000s. And so I think you’ve seen this movement of normalizing the language of health equity, and there are a lot of young people who understand that the white savior complex of global health is no longer tenable. We need other ways to be in solidarity, and we need to come with humility into any communities that are not our own, whether we’re working in a different part of the city that we’re not from or we’re working in foreign countries. How can you really be in solidarity with a community that is not your own? So I think it’s super encouraging that people who are 20, 21, or 22 years-old have language for this and understand it in a way that I never did. I think we now have to change our institutions to model health equity, whether it’s our local institutions, our universities, or at the multinational level – the World Bank, the IMF, PEPFAR and USAID. There’s a hunger to do meaningful work in the world. And I think people are leaning into that more so than was the case when I was an undergraduate 20 years ago.
HPR: We’ve talked about the role of healthcare professionals and policy and institutions. What advice do you have for students or citizens who, even if they don’t become healthcare professionals, want to be engaged in health equity and support those ideas and movements?
SS: I would say early in your career, try to immerse yourself as closely as possible to the problems that you’re trying to solve. I think a lot of times there’s an allure to become a McKinsey consultant, and it pulls you into another trajectory that changes how you understand the world. And so, for example, if you want to be a journalist and a foreign correspondent, you can’t only go to journalism school. You have to apprentice yourself to somebody who’s doing that type of journalism in a thoughtful and hard-hitting way to learn how it’s done. And if you want to really shift health equity in communities, you have to sit with community organizations and people asking questions in ways that community health workers do, who have understandings of communities in ways that physicians don’t. So, by the time you become a “professional,” you’re proximal to suffering in deep ways that allows you to understand how different structures manifest in communities – how different policies are connected. I think that only comes with making a conscious choice early in your career to step in and lean into some of those jobs that are a little bit less attractive on paper, but overall as time goes on are more rewarding.
Image Credit: HEAL Initiative / Sheila Menezes