Dr. Sriram Shamasunder, Co-Founder of HEAL: The Power of Perspective in Caring for the Underserved

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, workforce development and healthcare explore new innovations and approaches. I’m your host, Van Ton-Quinlivan CEO of Futuro Health.

One of the attractions of being a healthcare provider is the variety of ways you can make an impact, and our guest today, Dr. Sriram Shamasunder, is a great example of that. After training in internal medicine, he specialized in tropical medicine and hygiene and spent several months a year in underserved settings around the world, including Liberia, Haiti, Burundi, India, and even locations around the U.S., including South Los Angeles..

What he experienced providing healthcare in the aftermath of the earthquake in Haiti prompted Dr. Shamasunder and a colleague to create the Health Equity Action and Leadership initiative, or HEAL, at UC San Francisco. HEAL offers two-year global health equity fellowships that train providers to serve resource-denied populations. As they put it, HEAL transforms health workers that in turn transform health systems.

I’m looking forward to learning more about HEAL and the opportunities and trainings involved in doing this type of work. Thanks so much for being with us today, Dr. Shamasunder.

Dr. Sriram Shamasunder: Yes, thanks for having me.

Van: So, Sri, let’s start by having you tell us your background and what drew you to working with underserved communities, both in the U.S. and abroad, and maybe give us an example of best practices that we can learn from elsewhere and import here into our work locally.

Dr. Shamasunder: Sure. So, I grew up in rural Southern California, probably like sixty miles outside of Los Angeles. At that time, it was a working poor community in this town called Lancaster-Palmdale. My father was a doctor and he was an oncologist and I think one of the things that I saw in terms of him being a physician, is that oftentimes people would come up to us at the local restaurant and talk about the impact he had in their life. And so I think that was, you know, imprinted on me early.

Then my father, actually, when I was six had a seizure. He didn’t know he had kidney disease and needed a transplant very soon after. His sister came over from India and he received a transplant. We have some family inherited kidney disease so he had some cousins in India that also had the same disease in their forties and ended up dying. So,  I think there was this impression of how much inequity there is.  The fact that he had access to care, he had access to a transplant surgeon… even at a young age, I started to be aware of the different outcomes between my uncles and my dad.

As time went on, I had a chance to spend time right out of high school with my sister who was working in the slums of Bangalore. I went to visit her and I met a doctor there. I think that one of the things that was clear to me is there’s so many ways to do impactful work in the world and change the world but some of the physicians there immediately had the trust of the communities and it was a way to kind of embed yourself in this context where you immediately have something to offer to a resource denied community, a poor community. Then you build that trust and then you can start to think about ways to change the broader world. I think I really felt like being in medicine was a way that you can easily gain trust in these communities if you’re trying to have an impact in the world.

I spent a bunch of time in a Tibetan refugee camp in India as a med student as well. And then my residency training was at the county hospital in Los Angeles and we also worked at UCLA, which was the hospital in Westwood. Oftentimes you would see patients in Westwood that were in their eighties and nineties and they were dying of cancer or had ailments that came with advanced age. And then in the county hospital, oftentimes you would see patients that were in their thirties, forties, fifties with the same conditions and you saw this deep inequity. In the county hospital, they’re mostly brown and black patients, undocumented. So, you know, there’s this real questioning for me of how do I make the most use of my training and also impact patients that are struggling the most and poor? I think it’s a real education of the inequities that we see in medicine and how do we go about addressing that?

I could go on into some of the work I did in Burundi and Haiti, and a lot of times in the international work, there’s close proximity to the context in which patients live, especially in the global setting. Oftentimes you’re accompanying patients in their day-to-day lives. We do home visits. So, we track through and see how far it is, how hard it is to access the hospitals for patients, you know, whether it’s transportation or something else, we see the context in which they live. You’re walking with community health workers.

I think oftentimes in the US, there’s this siloing that happens where — whether you’re in an academic medical center or an FQHC or Kaiser or whatever your setting is — it sometimes feels like there’s a disconnect between the patients and the context of their lives and the medical system, the physical facility that we’re sitting in.

Van: Sri, a question for you…as we see the trend of care moving from the hospital to the home, do you think that intersects with your observation about proximity to the patient and the care that you’ve seen in global environments where there’s more trust?

Dr. Shamasunder: Yeah, I think you can actually deliver high quality care close to the home, and only hospitalize folks that can only get care in the hospital. I think the caveat is can you deliver a high quality of care with all these wearables and all the devices that are coming out equitably? There’s a worry that there’s going to be an inequitable divide. Like, for example, in my house, there is a pretty nice setup. I can imagine getting a high level of care, having an amount of information relayed back to the doctor or the providers to take care of me. But other patients that are in settings where potentially there’s not caregivers, that seems like it could be challenging. But if you can shift high quality care to the home, you know, that is a place where patients often feel the most comfortable.

In global settings, community health workers, that are mostly women, have the trust of the patients, know the patients, are from the community and deliver a lot of the care.  I think that shift has been a long time coming and we see some trends in California that community health workers are going to get paid and supported. I think that’s an important trend to watch.

Van: Well, we’ll continue to probe that discussion. I’d love for you to talk about how you’ve been able to manifest your impactful work in HEAL. Tell us more about what HEAL does and how it how it differs from perhaps other nonprofits that are in this space.

Dr. Shamasunder: Sure. So HEAL stands for Health Equity Action Leadership and it really came out of the work that me and my co-founder were both kind of raised in through this organization Partners in Health, which was started by Paul Farmer and has focused on work in in Haiti and Rwanda and other parts of the world, including with the unhoused population in Boston.

There’s a real focus on understanding the context in which patients live, accompanying them, being proximal to suffering to social suffering. I think that when I first came out of residency, I knew I was going to be in this space. I wanted to do work in resource-denied settings and I started to work in Burundi and Rwanda. I felt like I was making the same mistakes because I didn’t really understand the context. I didn’t understand the history of the place.  I kept seeing what we call as “stupid deaths” in global health…people were dying of things they should not die of, whether it’s asthma or bee stings or hunger. There was a sense that I was failing. I saw so much mortality in those six months.  I would spend six months internationally every year when I first came out of residency from 2009 to 2014.

We started HEAL because we felt like, how could we accompany people like me that wanted to work in resource-denied settings — whether it’s in poor communities in Oakland or Los Angeles or Navajo Nation or internationally — and then how do we support the colleagues that are there in Rwanda and Burundi that we often say are ‘running the marathon.’ So, people like me are sprinting. We’re there for four months, five months. But for the folks that are there — whether it’s Navajo Nation or in rural Burundi and Rwanda — how do we start a program that really supports their development and growth?

So, we started HEAL in 2014 and it really is about training and transforming frontline health professionals to serve underserved communities for life. That requires mentorship. It requires the correct curriculum, kind of reorienting what medical education is. It’s really about how do we get better at taking care of underserved populations? So, HEAL, every year has about twenty-five people. Half of them are post-US residency doctors; a quarter of them are Navajo.; a quarter of them are from the Global South. It’s this really incredible learning community where for two years, people are learning how to better take care of the populations they’re serving.

They’re very proximal to the communities. They’re doing clinical work and they’re doing project work to become better advocates, to become better leaders, to understand what we call the structural determinants of care. You know, the upstream factors that a lot of advocates talk about in terms of what makes people sick. Why are my patients getting sicker at younger ages or from diseases of poverty, etc.?

Van: I’m wondering if you could paint a picture of the behavior of somebody before they start a program and then how they’re sensitized and would behave differently after the program once they’ve spent some time understanding the structural determinant of care and maybe adapting their behavior, perhaps?

Dr. Shamasunder: Sure, sure. So, you know, I think this is the journey that I went on that I think a lot of Fellows went on. Medicine often has a language of blame in how we talk about patients, right? We talk about not adherent, or noncompliant, or lost to follow-up, or poor historian.  Those are very much part of the language of medicine where it’s a very personal failure of patients if they don’t get better. It tends to be a very individual approach because you’re taking care of one patient. Oftentimes it’s out of context of their entire lives.

I think when I was in Burundi, I was taking care of a diabetic patient and they were not taking their insulin. I had written the prescription for insulin, sent them with insulin, and then you know, their sugars were still very high. And so I complain that they’re noncompliant, right? But the fact is to gain access to insulin or pay for insulin, it was several days salary for them. It’s hard for some to gain access to a refrigerator. Oftentimes in rural communities, they’re burying the insulin in the ground because that’s the only way it keeps. So, you have all these contexts and all these barriers for a patient to have a good outcome from their diabetes. I think that that context is oftentimes lost on providers in medical school or nursing school where they’re not connecting the patient to the entire context of their lives.

That that’s true in rural Chiapas and in Uganda. A lot of our providers will say that before HEAL, they often thought that when patients had bad outcomes, it was very much an individual responsibility or a failure of the individual. And then as they go along in HEAL, it’s really connecting kind of the individual to the context in which they live…some of these social determinants of health of why patients struggle. If you do this work long enough, it allows you to become a better advocate and better leader.

In rural India, we have we have some folks that finished HEAL and they work in TB and they see tons of tuberculosis. But they also started a farming program for their patients because they realized that all the patients would travel to the city because there were no jobs locally, and when they went to the city, they were much more likely to get tuberculosis. So, in addition to treating the tuberculosis, they started a jobs program, a farming program in their local community that connected sustainable wages and sustainable jobs and the TB rates actually went down. I think those kinds of interventions that you see where you are obviously a doctor that’s going to treat TB, but you’re also going to think about the root causes of TB, tell the story.

Van: That is a really good example to help us understand the power of perspective, right? And how language and perspective affects how we problem solve. I wonder, Sri, what is your observation of value-based care and would value-based care actually enable more solutions like what you’ve discussed to come forth?

Dr. Shamasunder: I think so. I think you see some really incredible innovations in the Medicare Advantage population where if you’re taking care of a population, organizations are leaning into community health workers and home visits. There’s a real emphasis on keeping people out of the hospital and really looking at the entire context of people’s lives so we can address complex diseases. Actually, if it’s done across the whole system, it both saves money and drives better quality care.

Van: I sit on a council for California that’s looking at healthcare workforce shortages, Sri, and there’s a lot of discussion about primary care teams, especially given the shortage of primary care doctors. So, I’m thinking as you talk about home visits and community health workers…it seems like there’s a whole team that needs to be activated for this concept of primary care teams, right?

Dr. Shamasunder: Yeah, I think oftentimes we don’t learn in teams as our training can be siloed. Now, everybody talks about health care as a team sport and that is very, very true, but oftentimes we haven’t been trained in that context, especially in leaning into the skills for providing care in the home, providing value-based care and really understanding what is the role of every team member to better deliver that care?

Because HEAL is so interdisciplinary and it’s also transnational, we often have Fellows talk about getting the perspective of the nurses, getting the perspective from the community health workers, how they see the patient’s care. Those spaces don’t often exist. Oftentimes, you’re in a group of physicians talking about patient care or nurses are in their own cohort.  There’s good models for training that are I think are emerging or exist and we need to be trained like that, because I think oftentimes that’s not part of our training.

Van: Well, tell us more about HEAL’s work with the Navajo Nation in the southwestern U.S. I understand it’s quite an extensive portfolio of work that you have.

Dr. Shamasunder: Yeah, you know, we started working in Navajo Nation in 2014. As you may know, there’s a 30% vacancy rate for providers in Navajo Nation. There’s allocated funding — the U.S. government under the Indian Health Service has funding for those positions — but they have trouble filling those positions and that’s true across many Native communities in Oklahoma and Florida and even in California where we are. We see essentially this market failure where there’s a maldistribution of health workforce across different places. You have this, centering of workforce in San Francisco and Los Angeles, but in places that need it most, oftentimes there’s not enough of them.

So, if me and you were HEAL Fellows coming out of internal medicine, you would spend half your time in Navajo Nation. I would spend half my time in Liberia. Instead of going to a temporary staffing company that might have somebody come in for two weeks, that one job is shared by the two of us. For over two years, we share that job and that money comes to HEAL and we’re able to support a Navajo health worker, a Liberian health worker and the two of us as well. We also have some philanthropy supports for health workers, but that one job is financially sustainable — it’s not totally dependent on philanthropy — and it’s filling these vacancies.

Over the last nine years, we’ve had twenty-three physicians — 30% of the doctors that have signed up for HEAL — stay on in Navajo Nation. The Government Accountability Office in the US government has talked about how HEAL is potentially a solution, or one of the solutions, to address vacancies in Native communities. At the same time, we’ve had about sixty Navajo fellows that have come through HEAL and have stayed in the work. You know, we talk about moral injury and oftentimes for the Navajo provider, they’re in a rural community, they’re isolated, they don’t have a ton of mentorship and all of a sudden you’re connecting them to this global community where they’re learning, as well as having a mirror shown to themselves of how incredible they already are to begin with. And so they see themselves as an agent of change. So, you have both of these dual things happening.

Two Senators from Arizona and Utah also talked about how HEAL should be funded by the U.S. government because programs like HEAL are having this impact. I think one of the major impacts that we’ve seen is the ability to have people be recruited and retained in these communities. It has been an important part of our work in Navajo Nation.

I’ll briefly mention that during COVID — because we had such strong relationships in a community that has had historical injustice and a lot of trauma — we were able to really lean in. In March of 2020, Navajo Nation had the highest COVID rates in the world per capita. UCSF had shut down in February of 2020 because there was this concern of a surge that never actually materialized so we were able to send sixty nurses over four months, keep the respiratory care units open and I think there was a real solidarity of what can an institution really lean into supporting Native communities and what does that level of solidarity look like? I think that was a really impactful moment for HEAL.

Van: Well, going back to your story of you watching your father in action in the local community, I’m sure he would be so proud to see your impact in all these important communities across the country and the world. So, congratulations.

Dr. Shamasunder: Thank you so much.

Van: Let’s talk about burnout among providers, because that’s been a huge issue, and at the root of it for many is what’s referred to as moral injury…working in a system in which they feel disconnected from the purpose and meaning and unable to make changes to the system. Tell us more about what you think.

Dr. Shamasunder: Yeah, I mean, I think for most of us that have worked in the US medical system, there is this feeling that it’s fragmented. Despite the language of patient-centered care, there’s oftentimes profit at the center of conversations. And of course, you need to be financially viable and sustainable, but for a lot of us, we came in to medicine with a social mission of really serving populations, serving patients, improving their lives, taking care of poor patients.

Medicine is one of the spaces where it feels like we eat our young, where oftentimes the idealism that you come in with as a first-year medical student is gone by the end of residency. HEAL oftentimes is this mechanism to come back to that space where if you are doing hard things, if you’re being an advocate in communities and in structures that oftentimes feel like they’re not designed to support our patients in in deep ways and in different aspects of their lives, than doing it as a community and having mentorship, I think, can rejuvenate and be an antidote to that paralysis that so many of us feel when we’re dealing with large structures and large systems and poor patient outcomes.

I think that the moral injury is a huge issue. When we talk about increasing the health workforce and increasing the amount of providers in these communities, you are seeing a lot of turnover and burnout.  I don’t think that’s an accident because some of these jobs are set up in ways that we’re centering RVUs and we’re centering five-minute visits and the amount of volume you can push through. That doesn’t honor the provider and why we came into this work. So, that’s one of the things HEAL tries to be and where we try to have an impact.  Moral injury is now being talked about more and it’s really tied to burnout. It’s really this feeling of overwhelming paralysis in the context of these larger structures.

Van:  So, Sri, you mentioned mentorship, you mentioned a broader coaching community and in a way, there’s the affinity with a broader network that’s trying to tackle health equity, but also systems change. Are there other strategies to enable young providers to move along in their career that can help sustain them to go the distance?

Dr. Shamasunder: I think a lot of it is you can’t be what you don’t see, right? I’m sure people that are mentees of yours like to see someone in your position doing so many innovative things, and potentially having that conversation with you and being a sounding board is transformative.

We have Dr. Adriann Begay, who’s a professor at the University of Toronto, on our HEAL team. She’s a Navajo family medicine doctor who spent twenty-one years in the Indian Health Service. She talks about being like a teenager in Navajo Nation and seeing a surgeon who was Indigenous take care of her family. That was the first time she felt like, “Oh, you know, I can be a doctor, I can be a nurse, or I could be a health provider.”  I think that level of having people that are further along that are asking the questions that maybe you are starting to ask as a young person about why there’s such inequities of care and how does racism play into medicine, and how do I have an impactful career…like, that kind of modeling and mentorship is crucial and then having a community around it.

I think a lot of spiritual traditions understand this. In Buddhism, it’s called a Sangha, and in other places, a congregation. And so in healthcare, how do you find purpose and meaning? It’s with other people, and it’s with people that are in different stages of their career. So, I would say that that level of belonging that so many minorities and underrepresented in medicine don’t feel in the health system has been something that I think HEAL has been able to have some impact on.

Van: Oh, wonderful, wonderful. So, let’s close by giving you the floor to answer this question: what does the ideal future of care look like to you, and how best can we get there?

Dr. Shamasunder: (laughs) Oh, wow, that’s a big question! I would say that I’m super encouraged by the level of technological innovation like we saw in COVID. We all know that the mRNA vaccine came out in record time. And yet, we saw these incredible mortality rates in Indigenous communities, in Black communities…several fold over white communities. And so I think COVID was this moment where all of us are simultaneously seeing innovation and at the same time seeing these structural inequities that are embedded in our system, right?

So, in a lot of the incredible advancements that are coming — whether it’s CRISPR or precision medicine or biologics or AI — how do we make sure that it’s accessible to all patients across communities. I think we’re so far from that. HEAL is trying to grow across rural California. So we’re designing our program for rural communities — whether rural Northern California, or communities along the San Diego border with a lot of refugee and asylum patients.  That level of care, where there’s a strong health workforce that understands the context, has language concordance, looks like the population we’re serving, and making sure that the fruits of science really get distributed across these populations because I think that that has often been an afterthought and we’ve seen that kind of drive inequities. …I think that is a really important point.

In my mind, the future of care anchors a generation of providers into a social mission of care, which is connecting the context in which patients live and that’s the ethos of which

we train and live and provide care. And all the technology and the information that we have in the system of care, and the innovations around delivery of care is informed by that mind state and that approach to medicine.

Van: Well, I learned so much today on this podcast. Thank you so much, Dr. Shamasunder, for being with us today. I’m cheering you on and all of your works.

Dr. Shamasunder: Thanks for having me.

Van: Absolutely. I’m 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.