How did you become interested in global health?
I became interested in global health because, when I was fourteen, I had the privilege of going to Vietnam before relations were normalized. I had the opportunity to see a level of poverty that I had never seen before, and it was extraordinarily stark and extraordinarily painful. As a fourteen-year-old, I didn’t really understand how to process that experience, but I just hung onto it. When I went on to become a doctor, I always had this experience with me. I realized when I went into medicine that I needed to bring this international experience in Vietnam and figure out a way to participate in it, so that began to drive my interest in global health. As I started to do more and more work in it, I realized more and more the growing disparity we’re having in health around the world. I felt very strongly that we have an obligation to participate and to try to change that.
Why and how did you start Seed Global Health?
I started Seed because as I was finishing my residency, I had already had the opportunity to have worked in many countries. I [saw] first-hand that many people working in the medical field from first-world countries would come, deliver care, and then leave. The effects of what they had done would quickly evaporate. There was no focus on truly changing how things were done on the ground: by building capacity, by creating local ownership, and really, again, fundamentally changing the standards of care that are being accepted in the world — and that means really bringing in resources, really putting in the time and training.
At the same time, there is a huge interest in being involved with global health in the United States. A lot of my colleagues were trying to cobble careers together in global health but also pay back their loans. It would seem that there should be a way to bring together all those topics. In medicine we talk about Occam’s Razor, which is the single diagnosis that brings together all the symptoms and signs of a disease. There seemed to be a kind of Occam solution here: we could combine the demand to be participating in global health here in this country with the need abroad, and I’m not talking about the government.
I grew up in a house that was devoted to public service and I believe that, if we challenge our government to better, it can. So we pitched the idea to create a program that would be a part of the federal government that would provide loan repayment in exchange for international health service that would focus on education training and capacity building in our partner country. We managed to pitch the idea to the Peace Corps. Actually, we pitched the idea anonymously at a public forum that was being held by four Peace Corps directors. We asked the anonymous question: how would the Peace Corps feel about sending doctors and nurses abroad to be educators? They thought it was a great idea, and we used that to create a whole period of discussion, and the program began to take shape.
We created a public-private partnership between Seed Global Health and the Peace Corps (which is funded by Pepfar) to launch activities in three countries, originally Tanzania, Malawi, and Uganda. And so, we ended up sending US doctors and nurses to work as educators — faculty, really — at public training institutions in the three countries where we launched. The program has grown exponentially since we started. We sent thirty volunteers our first year and we’re going to be sending eighty volunteers next year to five countries. We are also going to be expanding to Swaziland and Liberia.
What advice do you have for young people interested in global health?
I think the most important thing is for people to realize that to be in global health, you can come from any field or background. In order to have an impact on global health, we need to, again, realize that there is a fundamental breakdown of the system on any number of levels in different countries. [This could] be appropriate buildings with good ventilation that an architect could impact [on] or it might be the need for art and design because art and design really can have an impact on people’s psyche and can serve as therapy after trauma. It might be business because private sector investment can, done wisely, help lift people out of poverty and make healthcare accessible. It may be administrative and management. It might be the supply chain. All this is to say there really is a breadth of need where people could make an impact. I think that the key is for people to be passionate about the work, and to decide that you are going to participate in helping to make a difference and not accepting the status quo, and to be creative about how we can find solutions to some of these big problems.
There’s this term thrown around in the news sometimes, “voluntourism.” How is Seed Global Health different?
I have never actually heard the term “voluntourism” per se, but I know exactly what you’re getting at. We actually feel very strongly that that is a major breakdown in how people engage in the field. If you are really going to effect change, you need to build trust and you need to build partnerships. Part of what makes Seed different is that we send our volunteers for a minimum of a year, which means they have the time to build trust, relationships, partnerships, all of which make them more effective on the ground. In the life cycle of our volunteers, they are fully immersed in the beginning, they start to feel a lot of challenges, they are trying to build trust. It takes a while, maybe about six months into their time that they realize they are actually in a place where they can instill change. Many will want to stay longer, two years, because it takes energy and effort to get people onboard, to get people up to speed on how the system works there, what the formula is, what the drugs are, who you’re working with, and just gauging an understanding of how to do things. You lose that if you go for a very short amount of time. It takes a tax on site to integrate you when you’re just going to leave again. And so, it really takes a long-term commitment. We are very committed to looking at our longterm goals and returning to the site where we’ve already been working so that we can ensure that there is continuity across the years. We have taught over 350 courses at this point to more than 9,500 nursing, medical, and graduate students and hospital staff in those five countries.
I think that is really a collective effort on our part, and it’s fascinating for us on site. Here’s a great story — I had a white, male volunteer who was from San Francisco and he was under a bed trying to fix a catheter when a tour came through the hospital. And to the Ugandan host who was guiding the tour, one of the visitors said “Hey, who’s that mzungu under the bed?” (mzungu being the local slang term for white person) and the host said “that’s not a mzungu, that’s Ari, he’s one of us.” I think this example is a real statement about how we have been able to have our volunteers integrate and have an effect over time, and we are really proud of it.
How does Seed’s approach differ from other non-governmental organizations (NGOs) and global health initiatives?
A lot of organizations that are prominently recognized in the global health sphere often are doing humanitarian work, which is incredibly critical and needed in times of crisis. It plays a critically important role for the agency and well-being of people who are caught in whatever the crisis is. But we often fail to transition out of whatever the crisis is into a longterm vision to create change that would be sustainable and lasting in a country. This is true of HIV, this is true of Ebola. As it is still early in the Ebola run, this is something to be cautious about. What we’re really committed to do is to strengthen health in a way so that countries can be self-sufficient, have their own indigenous doctors and nurses to provide high-quality care, and be able to keep training the next generation.
Many efforts have, in the past, focused on a single procedure or disease, without considering how those resources could actually be used for greater benefit. For example, if you are treating HIV and you are bringing people in to check for HIV, could you, for a marginal cost on your dollar, also check blood pressure and treat hypertension, give a blood sugar screening for diabetes, and could you bring your child in as well to make sure that the child isn’t suffering from diarrhea or some other problem? I think that’s a lesson we’ve learned in global health over the last twenty years: that we need to be thinking about how we can leverage our resources better, but also just that the system matters. You need very strong health assistants, which include highly trained people to be able to be responsive to problems in the health system but also to be creative in leveraging these resources to go further. We’ve tried to access that.
There’s a global shortage of 7.2 million doctors, nurses, and midwives, and that number is expected to grow; it’s projected to reach 18 million by 2035. Yet people are at the frontline of any kind of healthcare delivery because they’re the ones who can help interpret the finances, ensure that there is follow-up care, [and] understand their unique economic barriers to healthcare, and especially their determinants of health. Health is complex, which means you need a specific facility to understand how to solve problems within health. People are going to be central to that. People can write grants, bring infrastructure, [and] increase the resources, and so those are the reasons we leave it up to the people. Seed is one of the only NGOs working in these states, and we are also very dedicated to working with local government in order to build up the public sector. [By] just focusing on an individual city or one individual institution, you can’t bring the scale of change as widely as you can when you try to work with government to change the system.
How would you describe Seed’s relationship with local governments? To what extent do you feel you are representing the United States in these countries?
Seed is an independent 501(c)(3), but we do partner with the Peace Corps. A lot of our programs are bringing a new kind of healthcare diplomacy; we are sending Americans abroad in a very culturally sensitive and integrated way, out with their own agendas but responsive to our priorities, which is critically important if you want lasting change. If there is local ownership, it will actually be adopted, absorbed, and then carried out by the host institution or country, and that’s the key. By being willing to work with governments, we have been able to bridge that much more effectively. I think that this is incredibly important to the work yet to be done. We are very committed as an organization, and I think I can speak for Peace Corps when I say that Peace Corps is also committed to working with local governments and local institutions.
I think that’s part of the reason we have been able to do so well; we really do try to come in, listen, and observe long before we actually try to do anything. We tell our volunteers to spend three months just understanding where you are, to build relationships — go to weddings, go to funerals, have tea, go and look and learn and listen. There is so much context to understand before you can understand where the opportunities are where we can potentially make a contribution. I think that’s a really powerful lesson for this kind of work. Many of our colleagues will tell us that they know much better how to treat HIV/AIDS than we do, and it’s true. They do it day in and day out. But where we may be able to add value is how do we manage not keeping it here, [but] where can we implement the change that might actually make the ability to provide care more effective and go farther? For example, Steve Humphrey, who was one of our volunteers in our first year, worked very closely with the now head of internal medicine at Muhimbili University of Health and Allied Sciences. They created a new congestive heart failure unit that basically ended up rearranging how patients got admitted and what the education and care around those patients was, so they could take care of more patients in less time and more effectively. As partners, they started publishing things together and really started to transform education, research, and care in the East African region. One cool thing is he actually went back to Tanzania this year to teach a follow-up course, and he was able to visit one of his former cardiology fellows, Dr. John Meda, who is now the head of a cardiology department at a different university. We’re starting to see the ripple effect of the work that we’re doing.
What kinds of challenges have you faced in developing the program, and do different program sites pose different challenges?
Every country is different and every institution in each country is different. There are certainly different challenges depending on with whom and where we’re working. I think that one of the biggest challenges for us is that we are a public-private partnership and that Seed does rely on private philanthropy to uphold our end of the program. We provide the option of loan repayment for every volunteer that serves. This is an incredibly important assessment to ensuring that volunteers don’t have a financial barrier to service. Most health professionals do carry some kind of debt. For example, medical school costs upwards of US$200,000 by the time you graduate. This is a really important piece of our program, but it has to be done through private philanthropy. We have had the challenge of ensuring that we are sustainable from a philanthropic standpoint, through the contributions to our public-private partnership.
There are always challenges to working on the ground. In another country, you want to make sure that you are being culturally sensitive and appropriate; that has all sorts of roadblocks that we try to learn about. We certainly have had challenges around volunteers that very much have struggled, and rightfully so. I just had a volunteer today who looked at me and said “I just have so much debt, debt that I would not have if I worked in my own country.” It’s really hard to keep … going, [but] when you see so many people dying, you need to. Again, it is really because of a lack of resources and a lack of training and that’s what we’re trying to change. That can be an incredible challenge.
We also had challenges around working with the US government. There was a lot of work that went into building a really strong and close relationship with the Peace Corps. I am really proud that within a year we have built that. They are very responsive, very collegial, but we definitely needed to meld cultures when we first started.
What about Seed are you most proud of?
For Seed, I am most proud that we have been successful enough to be growing at the rate that we are growing. Our program is going to double next year. We are going to be in five countries, close to twenty sites. We are going to have over eighty volunteers. To date, we have sent about 105 volunteers. By March 8, 2016, we had trained close to 10,000 doctors, nurses, and midwives. Next year, when we go to 80 volunteers, our impact is going to double.
It costs us about US$650 per person we train, and if each person we train can pass it on to a hundred patients, a number we know is a conservative estimate because the wards are usually overflowing when we’re there, that’s US$7 per patient’s life. Just the fact that we have hit this kind of economy of scale is really exciting.
What are your goals for Seed’s impact?
The goal for us is simple: that we will no longer be needed. Essentially, we will train our successors so that they will take over the job that we’re doing now. That really has been our hope. I think that the key to that is that we are providing high quality education with breath and depth in a way the health professionals we train are excited to stay in their country to continue the investment.