Ep. 2: Lisa Adams, Associate Dean of Global Health, Dartmouth College. Topic: Global Health

Kathy: Hi everyone, and welcome to Episode 2 of the Smarter Healthcare Podcast. If you’re a returning listener, I’m glad you enjoyed our first episode and decided to come back for more! To our new listeners, welcome – and I hope you enjoy our conversation today.

Today’s guest is talking to me about a timely topic – global health. Lisa Adams works at Dartmouth College in Hanover, New Hampshire as the associate dean of global health. She is also director of Dartmouth’s Center for Global Health Equity, director of global initiatives, and an associate professor of medicine in the section of infectious disease and international health at Dartmouth’s Geisel School of Medicine.

Lisa and I spoke at the end of January. I want to give you this context because we spoke about the coronavirus, but obviously things are changing so quickly with it. So while some of the numbers that Lisa talks about are out of date – even only a short time later - the essence of her message is not.

I hope you enjoy this conversation.

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Kathy: Hi Lisa, and thank you so much for joining me today.

Lisa: Thank you for having me.

Kathy: It’s very nice to be back here in Hanover, New Hampshire, where I went to undergrad, it’s just as cold as I remember, and it’s always nice to interview a fellow Dartmouth alum as well. So Lisa, my first question for you – how did you first become interested in global health?

Lisa: Well it’s interesting, because I would say – I went to medical school, knowing that I wanted to work with underserved populations, that was a big part of my drive and motivation, but I entered medical school in 1986, and the term global health didn’t even exist. There was sort of international health, some of my classmates had been in the Peace Corps, but it really didn’t exist as the academic discipline and field that it is today. I ended up – knowing that I wanted to work with underserved populations and addressing health disparities – thought that might be domestically, and I did some work with groups like Health Care for the Homeless, but it was in my last year in medical school where I did a rotation with the Indian Health Service, out on the Navajo reservation in Tuba City, Arizona, and that really opened my eyes and heart to working in cross-cultural medicine, cross-cultural healthcare delivery, and I sort of sat on that desire as I went through residency, and then when I was a senior resident, Albania had just opened its borders. My family’s originally from Albania, all four of my grandparents actually had immigrated from there, and this seemed to be an incredible opportunity to think about returning to that country and seeing if there was a way that I could contribute. I was in my final year of residency training, I went over there with great aspirations and hopes, and learned that I had a lot to learn before I could engage effectively in global heath, including learning about healthcare delivery and healthcare systems in other countries. Again, when I finished my residency, I ended up working with a group called Doctors of the World, now called Health Right, based out of New York City, and worked actually in Kosovo, with a predominantly Albanian population and, again, that was what really hooked me. The work that I did there ended up being a tuberculosis control project, and that is what set my life on the trajectory for working in tuberculosis care and prevention that I’m doing today.

Kathy: Great, and so, much of your work does focus on tuberculosis. Here in the U.S. it’s been virtually eradicated. How widespread of a problem is it still globally?

Lisa: It’s still quite a problem globally. We estimate there are about 10 billion cases each year, and tuberculosis now has the dubious honor of being the number one cause of disease – cause of death from an infectious disease. That means that it has, yes, now superseded the deaths from HIV. So about 800,000 deaths annually from HIV, 1.2 million from TB. So still very much a problem globally. The other point that I make is how common this is, is to think of it this way: TB can exist in two forms – a quiet or dormant form, and then the active disease state, which is what we think of when we talk about diagnosing and treating people with TB. But TB in that quiet or dormant state is so prevalent that if you were to line up the world’s population in single file, every fourth person would have TB in that dormant state, so about a quarter of the world’s population. Now the good news is that we’re making great strides and great progress in reversing the trends, and we’re seeing decreases each year in the number of cases that are detected, and the number of deaths that we’re seeing. But we also know we need to accelerate that progress if we want to reach the global targets that we have set for eliminating TB eventually.

Kathy: And what are some of those specific steps that we’re taking right now for TB?

Lisa: Yeah, so there’s some exciting new news after many, many years without many breakthroughs in either TB treatment or diagnosis. We now have some new diagnostics, and we have some new drugs that are available. The problem with treating tuberculosis is that patients need to take a combination of medicines for many months. Minimum of six months, if you have drug-susceptible TB, and that can be up to two years if you have drug-resistant TB. That’s just been a burden on patients, their families, and healthcare systems. So some of the drugs that we’re working on now are going to allow us to shorten that course of treatment. And we know - and they’re less toxic. So we know the combination of those two factors will, we think, allow us to really address TB and particularly the concerns around drug-resistant TB. If we can really have an effective, shorter-course regiment, I think that’s going to be what’s going to allow us to make great progress.

Kathy: Great. Now one thing that’s in the news right now is the coronavirus. How concerned should we be here in the U.S. and how concerned should people be around the globe?

Lisa: Yeah, great timely question. As we all know, many of us in the healthcare field, and in public health, in global health, are following this and monitoring this very closely. Currently the U.S. Centers for Disease Control and Prevention has said that the risk to the general public in the U.S. remains low. Which is really great news. And I am very pleased to see the many steps that are being taken internationally to help control further spread of the coronavirus. I think we all learned a great lesson from the experience with the SARS virus, and I think that the difference here is that we are seeing much more international collaboration, and I think many public health officials and healthcare providers are trying to be very proactive in how we’re going to be addressing this. I can also say as we know the number of cases continues to rise, I think today’s reports were more than 6,000 cases, more than 130 deaths, and even in the U.S. while we still only have 5 confirmed cases there’s about 90 individuals who are still being examined and investigated for potentially having the virus. So I would say this epidemic has not peaked yet, I think we’re going to continue to see cases rise, but the prevention efforts that are in place I think are going to help us contain this.

Kathy: Now viruses such as the coronavirus in years past, you mentioned SARS, we’ve heard Zika, Ebola, are these on the rise right now, or is it more that we’re hearing about them more because of our 24-hour news cycle?

Lisa: Yeah, well, we certainly are getting more information about these outbreaks that are happening across the nations and continents that seem far away from us, but I would say the biggest change over the last few decades could be summed up in one word, which is globalization. We are a more inter-connected world than we have ever been. You think about air travel, the U.N. estimates that about 1.4 billion people travel internationally each year, so we are just able to travel and have contact with places where there might be emerging new pathogens. So both I think, learning about it, and also the fact that people are able to travel so freely and so quickly in places is going to contribute. And as we know that’s what’s happened with the cases of coronavirus that we’ve seen in the U.S. All five individuals who have been confirmed cases had recently been in the – what we call the epicenter of the outbreak. So I think that’s one of the biggest factors. We know too through evolution that pathogens continue to evolve. Most of the emerging pathogens we’re seeing today are zoonoses, meaning that they’re coming from – they exist in animals and they are jumping the species into humans. That happens at some fairly regular constant rate. It’s when that pathogen then develops that ability to spread from human to human that we see the outbreaks. OK, if it’s only going from animal to human it’s going to be a contained outbreak typically. So we know part of that is just life cycle and what we see with the evolution of pathogens. But I think it is the globalization and the interconnectedness, which is also in many ways to our benefit too because many of us have connections to places outside of the U.S. so I think we care more, and that’s going to help with our efforts to collaborate and work together to control these new pathogens.

Kathy: Now as you think about the most pressing global health issues today, what are some of the things that are bubbling to the top?

Lisa: Well, working in infectious disease, of course the overriding concern there is the development of drug-resistant pathogens. We’ve seen this with tuberculosis, we’ve seen this to some extent with HIV, and what we really need to do – and malaria as well – we need to be able to stay ahead of the curve, stay ahead of the pathogens, and be able to have drugs that we will be able to use in those instances, and use them smartly, so that we prevent further emerging resistance to those new drugs. But I think drug resistance is certainly, I often say, the thing that keeps me up at night, when I think about how are we going to work to effectively care and prevent TB, HIV, and malaria. Having said that, we also have to recognize that it’s the non-communicable diseases that we’re seeing also rise in low- and middle-income countries, so it’s the – it’s heart disease, it’s diabetes, it’s cancers. And there’s actually an important movement now to bring in practitioners who, clinicians who really felt like global health was the infectious disease world, maybe maternal child health as well. But now we have people working on our initiatives around global oncology, around heart disease care and prevention, blood pressure control, diabetes control, so it’s really now becoming sort of an all hands on deck issue, and we’re bringing in many more collaborators.

Kathy: Now here at Dartmouth you focus on teaching global health to students. What do you think are some of the most important skills that they need to learn?

Lisa: So we spend a lot of time prepping our students before they go overseas, and I will say one of the things that I like to impart upon them is the importance of equity, and not just in the program goals and in the work that we might be trying to do in partnership with our international collaborators, but also in our practice, and how we conduct ourselves. I often say to my students, “You’ve gotten into Dartmouth because you’re really smart and outspoken and assertive, have great ideas, and share them in an articulate way, I want you to unlearn most of that now, I really want you to sit back and move into listener mode.” And that, I think is the way that our students, and frankly all of us who work in global health, can be most effective. We really need to work, if we’re going to work in partnership, and those partnerships are going to be equitable, we need to spend a lot more time in listener mode, in fair and balanced dialogue with our partners, but particularly for our students. Of course, their safety, and working with them around their project design and making sure that there is rigorous academic, scientific methods, et cetera to the work they do is one part, but it’s so much more than that and just buying them a plane ticket. It’s really talking to them about how they are going to work and function in an equitable partnership.

Kathy: I think that’s probably good advice for people even outside of global health, just being a good listener. But you talk about some of that checking your privilege, which I think probably goes along with that.

Lisa: Yeah, I often say we need to do several things, we have to recognize our privilege, and then sort of I say, check it at the door before you enter the partnership. And I talk about doing three things in global health, to make sure that our partnerships are equitable. I encourage us to think about how we’re going to decolonize global health, and the practices of global health. We really need to think very carefully about our language and our attitudes, and our approaches to ensure that we are not replicating previous colonial, or neo-colonialist practices or behaviors. And you have to be really conscious to think about how that can happen. You have to be very intentional. Secondly, we spend a lot of time with our students and really anyone that engages with our programs in talking about understanding the context. Understanding the place where you’re going to be working, the culture, understanding what historical legacies of colonialism might be there and the impact that they can still be having, you have to understand the complex social and economic forces that today continue to produce the disparities that we seek to address. And thirdly, I make sure that our programs really practice reciprocity. We often say that it’s only through reciprocity that we can ensure that the benefits of the partnership are equalized across the partnership. So for us in a very practical manner that means that if we’re willing to send our students to work with our partners in Tanzania, or Peru, that we need to be willing and able to receive their students and their learners, and think about how we will again maximize and equalize the benefits to all. I’ll tell you – our partners notice that. They understand and are really attentive to when we talk about how we want to emphasize reciprocity in this relationship. I think, unfortunately, it’s not done often enough, but I think it’s maybe one of the key ingredients or secret sauces to having an equitable partnership.

Kathy: How important do you think it is to include diverse perspectives or multi-disciplinary teams in some of the work that you do?

Lisa: It’s absolutely critical. And I always say that we have – you can design the best health intervention in the world, and if you don’t understand, again, the context, the culture, the community that you’re working with, if you haven’t – from day one – co-designed that intervention, and really brought in the right stakeholders into the conversation, you’re likely setting yourself up for failure. I always engage a social scientist, a medical anthropologist, or a medical sociologist on my team because I know that as a clinician, global health practitioner, I can only – my perspective will only address one piece of the puzzle or problem, and we really need the social scientists on the teams. Similarly, with our partners’ teams, they often also bring in, of course, the public health and perhaps medical specialist, but they also often times will bring in the social scientists and social workers and others that really help us understand how we’re going to work with communities.

Kathy: Now what do you think are some of the things that either you or your colleagues – are the most important things that you’ve learned from those health care leaders abroad?

Lisa: Many of our partners are in low- and middle-income countries, and they’ve developed particular efficiencies because they’ve had to. The limitation of resources has in many cases forced innovation and efficiencies in ways that we don’t always do so here in the U.S. And I think some of the sort of key innovations are – I think we’ve learned how to do good community-based care, and how to extend the health care work force through what in most countries where I work are called community health workers, and in the U.S. now we’re starting to adopt them more in the term of health coaches, but trying to find those kinds of advocates and people who can really be a linkage and save the physician to do the strictly clinical work, or mostly clinical work, even save the nurse to do most of the nursing work, but have someone who is that bridge, to the health care providers for the patient, that they can ask questions of, that they can have a different kind of rapport from. Ideally it works best when that health coach or community health worker is from the patient’s community, if they have a shared culture, language, experience, but I do think that that’s something that I’ve seen work so well in some of the countries I’ve worked. Rwanda is one of the places with one of the most robust community health worker program, something like 45,000 community health workers for a population of about 11 million. Those are the kinds of things that I think we can learn from our international partners. And we are starting to and starting to adopt some of those practices here.

Kathy: It seems like models such as that could definitely help us in terms of controlling some health care costs here.

Lisa: Exactly, absolutely, and again, with the innovation and efficiency often comes cost-effectiveness.

Kathy: What do you see as some of the most innovative areas in global health right now?

Lisa: Certainly when we think about innovations in healthcare and healthcare delivery we often think about the use of technology, and there’s no doubt that that is having a – playing a dramatic role in, again, extending the reach for healthcare and healthcare provision. Specifically, I think in the mental health space, we’re finding that the use of cell phone messaging or even video conferencing for the work in tuberculosis care and prevention. Sometimes we’re using actually text messaging also and video for ensuring that patients are adhering to their treatment, so that’s one space that I think there’s still lots of exploration happening. I will also say too that the new diagnostics and drugs that we’re seeing being developed are the other area too which as I mentioned we really do need if we’re going to be effective in getting over the finish line, with getting rid of some of these diseases, really pushing them towards elimination and eventually eradication.

Kathy: Are there any other advancements that you think will be most impactful across the globe?

Lisa: I think again this issue around addressing drug resistance effectively is going to be one of the key issues that I think we’re going to have to work together as a global community. I will also say that I think the use of building stronger coalitions internationally and global networks is one of the ways in which I think we’re also going to make great progress in addressing and tackling some of the global health challenges that we’re facing. And I think an area – in order for this to be effective we really do need to be continuing to push for equity in those partnerships and those coalitions. But I think we’re starting to see that and I know we’re going to need that sort of level playing field, that balanced partnership in order for us to be effective in addressing the most pressing global health problems that are facing us today. And that’s again whether it’s the rise of - the concerns around infectious diseases that we’re seeing, or it’s the rise of the non-communicable diseases that we’re seeing, or whether it’s the newest pathogen that we haven’t even yet seen.

Kathy: Well, Lisa, thank you so much, this was a really great interview.

Lisa: Thank you. I appreciate the opportunity.

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Kathy: Thank you all for listening to this episode of the Smarter Healthcare Podcast. If you like what you hear, please subscribe on your favorite podcast app, and don’t forget to rate and review us!

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Until next time!