You can’t have an effective response to public health challenges without putting racial and social equity at the center of your approach, and one key way to do that is supplementing the healthcare workforce with “trusted voices” from underserved communities. That’s the view of Dr. Rishi Manchanda, a public health veteran and healthcare leader whose career has focused on developing new strategies to improve health in resource-poor communities. Through a mix of frontline and leadership positions, he’s helped provide care for homeless veterans, immigrant workers in rural areas, and communities in South Central Los Angeles. As an author and CEO of HealthBegins, he’s become a leading national voice on shifting the focus of our healthcare system to “upstream” causes of poor health status – such as access to quality food and housing — and creating equitable access to care. Check out this illuminating conversation with Futuro Health CEO Van Ton-Quinlivan to learn about “upstreamists”, the workforce-equity connection, and what COVID is teaching us about our healthcare system.
Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused, education, health care and workforce leaders explore new education to work approaches and innovations. I’m your host Van Ton-Quinlivan CEO of Futuro Health, and today I’m happy to welcome Dr. Rishi Manchanda, a physician, author and health care leader whose career has focused on developing new strategies to improve health in resource poor communities. Through a mix of frontline and leadership positions, he’s helped provide care for homeless veterans, immigrant workers in rural areas and communities in South Central Los Angeles.
On the national stage, he’s best known for a popular TED Talk and book about “upstreamists — health care workers who improve care by addressing social needs such as food and housing. Currently, he is president and CEO of HealthBegins, which works across the country to improve the social drivers of health and equity. I’m looking forward to talking to him today about the intersection of public health and workforce development. Thanks so much for being with us today, Rishi. Can you start by telling us about yourself and what led to your interest in medicine?
Dr. Rishi Manchanda: Well, first, thank you so much for having me and thanks for the opportunity to join you. I think this is going to be a fun conversation, just having had a few conversations with you in the past. So I’m looking forward to this. And “hi” to everybody who is listening in. So I, as you said, am a physician. I’m a public health doc. I decided to go into this field of medicine and of public health because of early experiences that I had going back to college and the work I did after college in India. One day in a rural part of India that I was visiting for about two or three months, I was accompanying a local nonprofit organization that was staffed by clinicians, community health workers, general community development staff. And I joined the clinician on the team to see some patients. And it was about two or three hours in the clinic. And then she stood up and she said, “well, now let’s go and continue our day” and we drove to an outlying community and went door to door to support the broader campaign, along with about 20 other people who were doing door to door sanitation surveillance work — talking about latrines, talking about hygiene, and not just talking about both those very essential things, but also checking in with people saying, “how are you doing?” And you could tell that this wasn’t the first time that this group had met with this community. There were deep relationships, smiles, hugs exchanged. They were talking about health in the broader context of people in their homes and their communities. And I thought that’s exactly the kind of profession I want to have. I want to be as comfortable working in the walls of a clinic as this clinician was, as I can, being able to be effective, along with partners in the community, to talk about people, the lives that they have in their homes and health. So it was that early exposure and many others like that that allowed me to pursue this career. I’ve had the good fortune of being a primary care doc with a public health heart all my life.
Van Ton-Quinlivan: Well, we’re so glad that you had this early exposure to public health. As I mentioned at the beginning, you have helped serve a variety of underserved populations as a physician and an administrator. What drew you to this work beyond the early exposure in India?
Dr. Rishi Manchanda: As simple as it may sound and as hokey as it may sound these days, you know, I got into medicine because I thought this was a means to be able to understand how to enter a broader conversation about community and public health. It’s not the only pathway to have these conversations, it’s just the path that I chose to kind of enter into this broader conversation that we’re all in. When I signed up for med school, I applied for a program called the National Health Service Corps. The gist of the program is if you are committed to working with underserved populations, the federal government will, if you receive the scholarship, will pay for your health professional education, in this case, medical school. So I had the good fortune of being able to get the scholarship and then finish my medical school and public health training. And that allowed me to work first in Venice Family Clinic, which is at that point one of the nation’s largest free clinics. It’s since become a community health center. After a year of working there, every Thursday I’d go over to South L.A. and work with community organizers and community health centers there to speak about issues of housing and whatnot. A year of doing that led to some wonderful opportunities. I was invited to join as an assistant medical director at a community health center in South Central Los Angeles, and I accepted the offer, which was a gracious offer to begin with. But I asked if I could modify the job title and they said, sure, you know, we just need people to help out. So whatever you want, just go ahead and do the work. The job title that we agreed to was the director of Social Medicine and Health Equity, which allowed me to spend my admin time, my eight hours a week that I had outside of direct patient care, to build programs and to start working, you know, on questions of how do you screen for housing and security, how do you address food insecurity? How do you talk about human rights, you know, and what’s the role of a clinic or clinician to be part of that broader conversation and advance these things? It was an incredible opportunity and one I’m always grateful for. That opportunity allowed me to fulfill my commitment to the National Service Corps while also doing the exact kind of work I wanted to do. And since then, I’ve just been privileged to be able to work in other communities that have had a lack of resources, but have had incredible insights so that when one kind of way to put a bow on this answer to your question about why…the need is greatest in communities where resources are the least. The insights, the innovations, the passion is also greatest in those communities, oftentimes because you have incredible experts, incredible leaders who out of necessity, you know, have been advocating, innovating, serving to address those needs. “The Force” was strong, right, in underserved communities across the country. And it’s because there’s so many incredible people from promotores de salud to community health workers to organizers, to housing advocates, to moms and dads who are every day, you know, finding new ways to be able to do right by their families. I mean, so many incredible people that I have the privilege of, frankly, not just serving, but learning from. And I became convinced that this was the space to be in. If you’re going to go into health professions, from my experience, I highly recommend applying those lessons in places where the need is greatest because the rewards on a personal level, on a professional level are immense.
Van Ton-Quinlivan: Well, I can’t wait to jump into the discussion of social determinants of health, something you detail in your book, The Upstream Doctors. Can you help us understand what that phrase means and how should we think about this?
Dr. Rishi Manchanda: What I found is that, you know, working in South L.A, when I would say social determinants of health the term just barely came out of the mouth before the eyes would glaze over. OK, got it. OK, that’s good. But how do I talk about that over Thanksgiving? You know, how do talk about this? So what I found necessary was to communicate through “the upstream parable”. In this parable three friends come to a river and much to their dismay, they see people in the water and they’re not swimming leisurely, they’re drowning. Children, adults, the elderly. They’re being pulled towards a waterfall and obviously it’s perilous. So the three friends do what many of us do in the health professions or in any kind of service oriented industry. We jump right in. The first friend says, “I’m going to save those who are at risk of drowning, those closest to the waterfall and rescue those.” The second friend over time who’s doing the same thing in rescuing people, she says, “well, I have an idea. Let me take some of the vines along the banks of the river and the branches I can see and weave together a raft and usher people to safety. Over time, they continue to do this work and it’s effective most of the time, but they start getting fatigued, they start getting a little burned out. They start seeing sometimes the same people they saved last week in the water again and out of this fatigue, out of this cognitive dissonance, they start blaming the people in the water that they’re rescuing rather than asking kind of deeper questions. This is a story of specialty care or specialists and primary care. The story of the rescuers are the people that you want when you’re in dire straits. The ICU surgeon, nurse, the critical care surgeon, the oncologist, the you know, the people that we need when we have serious medical problems. Raft building is primary care, right? That’s the work of coordinating the branches together and creating essentially through a team, the ability to usher people to safety, to provide them with the clinical preventative services and the various other relationships, the continuity over time so that people don’t have to end up just in need of rescue. And so far, that’s been the story of American health care. We’ve been telling ourselves the story in crafting our entire conversations around workforce largely within that frame of the rescue and the raft building and clearly having important debates about the allocation of resources between downstream specialists and, you know, primary care raft builders. But as I mentioned, three friends have jumped into the river. And the story essentially of American health care is only two thirds complete. What happens in this story is that those two friends eventually recognize there is another friend that jumped in the water with us. “Where’d she go?” She’s swimming away from them. And they shout to her, “where are you going? There are people here to save.” And she shouts back– the upstreamist in the mix — she shouts back and says, “I’m going to find out who or what is throwing these people in the water. That third friend is the part of the workforce that I’m trying to elevate in my career. I model myself as an upstreamist, that’s the name I give to ourselves. The upstreamist is somebody who is who is part of the health care profession and whose job specifically is to have the knowledge and the skills to be able to understand, help their system and team members understand and then collectively marshal resources to address the upstream factors. And that doesn’t mean the health care system’s job is to fix housing or food or, you know, social isolation. But it is health care’s job to create the upstreamists, to create a link between our downstream “sick care” system and the other public health, other upstream sectors. The upstreamist is really kind of like the interstitial tissue, the connective tissue, the person who is trying to connect to our systems of health care delivery, to the broader systems of community change. And that’s the way of talking about both the social determinants of health as well as talking about the role of health care.
Van Ton-Quinlivan: Oh, I love that parable. That’s very helpful to all of us who aren’t from the health care world. And I was wondering if you could just sort of highlight for us, is there a role for workforce development in the upstreamist’s world?
Dr. Rishi Manchanda: Absolutely. The question that started to arise, especially in the past five years, has been, OK, so how do we train upstreamists? What are the competencies required? What does this look like in the workforce? And as you know, Van, in the past five years in particular, part of the reason those questions are happening is because of the broader kind of shift that’s been happening, the shift towards value and outcomes and equity from health systems. And Kaiser Permanente has obviously been at the forefront of both asking these questions, especially with Bernard Tyson and his legacy. You know, clearly, you know, what Bashar is continuing to kind of carry forward. There’s an incredible number of people in the country who’ve been pushing the envelope and saying, “what’s our role as a health system to be able to, you know, ask these questions as well as try to help address them.” Now, the question about how to do that rests on the question of workforce to your point. So what we’ve done is identify six core competencies that are required. These core competencies range from understanding the essentials of both population health for distinct panels of patients, to community health, which is defined by geographic kind of work. You know, and in that same vein, understand the essentials of social needs, which are individual experiences, to social determinants, which are community experiences to structural determinants, which are a societal thing. So we know, of course, like there’s food insecure individuals, but they live in food deserts, which is a social determinant, and those food deserts are there for a reason, and that’s because of redlining and historic issues of structural racism. Part of the competencies is understanding these words, understanding these concepts, but other competencies include upstream quality improvement. There’s also competencies around understanding race, power and class because any analysis of who or what is throwing people in the water would be incomplete if we didn’t name these kind of factors of race, or racism more specifically, power and class. And that requires, you know, a structural kind of competency, as some are calling it these days, that is often missing from a lot of our health professions training. So anyway, there are six different competencies and we are now working with partners, including the American Medical Association and others, to help to bring educational modules online and then improve the knowledge of the upstreamist workforce of the future and thereby then take those that improve knowledge and then put it into practice to improve the competency of this and then work with even a more forward thinking group of folks who want to move from just knowledge and competency to mastery, you know, becoming true leaders in this kind of space. And that’s our approach right now.
Van Ton-Quinlivan: I’m so glad that you’re driving this work. And so, we have come to realize as a society that the COVID has revealed a lot of disparity in health care. And so if there were more widespread adoption of community based workforce principles, what do you hope to see as the improvement in health care disparity in the future?
Dr. Rishi Manchanda: So I’m glad you asked about the community-based workforce principles. What we recognize is that in every disaster response effort, a community-based workforce is an essential ingredient, an essential component of how to be able to provide response and recovery to any disaster, including a pandemic. What I mean as a community-based workforce is something that is in addition to formal public health workforce, formal governmental public health, where we clearly need more resources, and a community-based workforce is also distinct from the formal health care workforce — the doctors, nurses, medical assistants, many others — in the formal health care system. For example, community-based nonprofits, community health workers, the trusted voices that you go to when you’re in a neighborhood and you go to the person who is putting together the neighborhood in a response to help the elderly person down the block who is living on their own. So we put together community-based workforce principles with allies across the country about five months ago. And we started then to create this alliance around it to help promote these issues. And the reason that’s important is because our underlying premise, to answer your question about equity is this: if we want effective pandemic response or recovery, if we want to make sure it’s equitable as well, we need to actually include community-based workforce members. You have to bring them in to care teams in the health care system, bringing them into contact tracing teams in the public health side, bring them in so that we can help to ensure that there is more equity and more effectiveness of all the things we’re trying to do. And what is true for the pandemic is true for the health system writ large, right? To be able to address the racial inequities, the economic inequities that clearly are shaping COVID, but also shape every other health condition. We need to tap into trusted voices in communities to be able to augment the interventions that every other workforce is trying to implement, both from health care or the public health side
Van Ton-Quinlivan: And so Rishi if you wanted to be one of these trusted voices that can help augment health care, what are examples of titles or occupations that you would want to pursue?
Dr. Rishi Manchanda: Yeah, so one of the most common titles is a community health worker. The American Public Health Association has come up with a definition several years ago. And largely what’s part of the definition is this point about being a trusted worker, a trusted member of a community who also is participating regularly in health promotion, health education and a whole range of roles. So, Community Health Worker is one title. There are a few related kind of jobs that are out there, from health navigator to community health educator. Some health plans right now are calling it community health advocate. There are Promotores de Salud who are kind of trusted members of the Latinx community, Spanish speaking. So starting with community health worker, looking at a community health navigator, community health educator, community health advocate. There’s a variety of different titles that are out there that speak to similar issues around what it means to be part of a community-based workforce.
Van Ton-Quinlivan: And just to clarify for our audience, you know, at the very beginning, we talked about the path to becoming a doctor, which people know is years and decades. What’s the length of time to become one of these roles in terms of investment in education or higher education?
Dr. Rishi Manchanda: Oftentimes, whether it’s a community health worker role or Promotores de Salud or various other kind of, you know, iterations of similar job classifications, what people do is to sometimes find pathways to get more formal training. And it doesn’t mean necessarily, you know, a formal degree. It means entering organizations that are community-based that help recruit those trusted voices and give them additional training in issues like hypertension management or, you know, contact tracing or whatnot. It’s essentially these are community-based organizations as well as some academic institutions. So, whether it’s community-based education or academic institution-based education, there are pathways for individuals who already have a degree of interest and a strong sense of trust and, you know, relationships with their communities. What we need to do, I think collectively, is to ask ourselves how we can provide pathways for more formal training, more formal education, more formal supports like the incentives that allowed me to become a doctor. How do we create more incentives for people who have this deep relational expertise? Right. Not necessarily the technical expertise that doctors are prized for, but the relational expertise, the community members like potential community health workers have. That’s the real opportunity, I think, that that we all face right now. But I don’t know if that answered your question directly.
Van Ton-Quinlivan: It’s a perfect answer and I’m looking forward to having Futuro Health work with you on that. So, Rishi we were you were a member of the California Future Health Workforce Commission, which issued a plan last year to eliminate the state’s primary care workforce shortage. What can you tell us about how those recommendations are playing out?
Dr. Rishi Manchanda: Yeah, it’s such a great question. It’s something I love talking about because it was a phenomenal opportunity to be a commissioner, obviously, on the state commission. The quick history is several funders came together and recognized several years ago that looking forward to 2030, we clearly saw a lot of shortcomings in terms of the number of health professionals. And the question was, “how can we start making plans now to be able to influence policymakers, to be able to invest in places where we need?” After a really long process, a lot of public comment, a lot of stakeholder engagement input from hundreds of actually stakeholders in the state, the commission then put forward a lot of recommendations, including top ten recommendations for making a major impact on the health workforce needs of the future, including primary care, including how to address the aging population that we have now and will have even more in 2030, including the rural-urban kind of gaps and disparities, etc. So one of our recommendations, and to your point about you know what impact or traction it’s had, it’s actually been tremendous in many regards. So, for example, late last year, Governor Newsom endorsed a major investment in expanding loan repayment opportunities to expand opportunities for physicians and other health care professionals to be able to work in underserved communities. Well, very akin to what I talked about with the National Service Corps, opportunity for myself — massive investment that now allows for even more individuals who come from, who look like, who are committed to serving minoritized communities, marginalized communities, rural communities…to provide opportunities now for them to be able to serve in those communities rather than feeling like they don’t have the financial wherewithal to be able to go into the profession, let alone kind of practice in the way they want to. Obviously, COVID changed the pacing of some of those conversations. But I’m proud to say that the commission’s recommendations have largely been met with very receptive ears from state government. And now it’s just a question of continuing to kind of see how all of us can learn about the commission’s recommendations and how we can then participate in the conversations around how to implement them.
Van Ton-Quinlivan: Yes, continue that important focus. And so let’s close out – I would love to ask you, as president of HealthBegins, which has partners across the whole country, you have a perspective on what’s happening nationally. So, what do you see as the biggest impact of the COVID crisis on the public health and health care system?
Dr. Rishi Manchanda: I think what COVID has done is to reveal longstanding challenges that many of us have always known about in the health care systems, longstanding challenges in terms of the structure of how health care is delivered, how supplies are administered or provided, of how public health systems are coordinated or not, and also the underlying inequities, especially racial inequities, of course, that I think we’ve all become as a nation more aware of the number in this generation at least. The challenge then is how can we actually come together to address it? HealthBegins is just one of many, many organizations, including yours at Futuro Health, that are thinking about ways to now step up and collaborate. We do know a couple of things. One is this is only something that can be done together. You know, this is the time for collaboration, for perhaps old incentives to kind of jockey for position where one organization tries to say, “OK, well, this is our thing”….we don’t have time for that. We need more than ever to give rise to collaborative leadership. Second is that I think, you know, when it comes to rising to this challenge, we certainly know that for those who were unaware of the importance of social determinants of health, of the upstream issues, COVID has taught us that it’s fundamentally important. If we want to suppress the transmission of the virus of COVID in the community, we have to invest in the upstream issues that can support people to stay healthy and stay isolated and care for their families and not have to have the same kinds of questions that were happening pre-COVID which is “do I pay for health or do I pay for food? Do I pay for the go to the doctor or do I pay my rent?” Those choices now are becoming starkly kind of difficult, especially as we see the massive unemployment issues that have been part of the fallout from COVID.
So the last thing is that this is about equity, equity, equity, right? I think it’s time for us to acknowledge that it’s not a choice of being more effective or being more equitable. The only way to be effective is to actually center our work on an equity frame, understand what this looks like, and that equity means then asking ourselves…like we might be saying these words, we might be understanding these things, but do we really have a deep understanding of what it means to do this, both with partners, with our own strategies, and frankly, also internally? What does it mean to actually raise the bar on equity? And that is a necessary discomfort that we all have to go through. We have to challenge ourselves because the structures that we’ve all kind of benefited from, that we’re all kind of part of right now have long been inequitable. So these are challenging times, but I think COVID has taught us that we can rise to the occasion by collaborative leadership, by really focusing in on the social determinants of health and the structural determinants of health, and lastly, kind of putting equity at the center of our conversations. And the good news is I see a lot of leaders, including you, including many others, you know, modeling what that looks like.
Van Ton-Quinlivan: Well, thank you for that call to action. I’m sure our listeners will agree with me that you, Dr. Manchanda, you’re just a wealth of knowledge, experience and a person of great vision for our country here. Thank you very much for being with us today. I am Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.