S3E21: Health on a Global Perspective

Harjit: Okay, Chloe, can I redo the opening? Okay, yeah. We see it. I'm recording. We're recording. Okay. So, because of the coronavirus, we have decided to do our podcast remotely from our house. So I hope you all will bear with us and these technical difficulties that we try to navigate.

So, with that, I want to welcome everyone to the Bundle of Hers. I'm really excited about today's episode. Remotely, we have me Harjit, Margaux, and Leen. We also have a very special guest, Dr. Adil Husain, who is a pediatric cardiothoracic surgeon at Primary Children's Hospital. And we had the opportunity to meet two years ago when he first came to the University of Utah, and he did a really amazing talk on global medicine. We are so excited to talk about this topic with Dr. Husain.

Margaux: We had been planning this episode on global health and global medicine for quite a while now, but it seems very fitting that we're actually doing it now in the midst of a pandemic. And so thank you for joining us in this very hectic time.

Dr. Husain: Well, I'm really excited to be here with you today and look forward to the experience.

Harjit: Awesome. So kind of just to set some ground rules, we love to start with definitions. For a lot of our listeners, if you don't know what global health is, basically the definition that I love the most is it's understanding how health is interdisciplinary and interconnected and how the health of one individual impacts the community, impacts the country, and then impacts the world. Dr. Husain, maybe we'll start with that. What is your definition of global medicine?

Dr. Husain: I think that's a great place to start. And I'm sure our dialogue today will weave in and out of the current pandemic and crisis we're in, where there's no better or truer example, where the health of one individual has profound implications and impact upon the health of others, not only in their community but worldwide. I think the other way of looking at global health, for many of us that have been privileged to be able to share our experiences on a more global stage, is the product of disparity and the issues that global health raises regarding the concerns for disparity. And so I think your definition is very appropriate. And I think the impact of that definition is more profound when you think about the disparity of how healthcare is provided for around the globe.

Harjit: Thank you so much for adding that very important point. I think it's one that we often think about as the Bundle of Hers. And I kind of wanted to start this conversation with your story. When and how did you discover global medicine, and why do you continue to do this work?

Dr. Husain: Well, I discovered global medicine back in 2007. I had just finished my fellowship training in pediatric heart surgery. And it felt as if it was a time in my life, where for the first time in a long time, I could hit pause and I had some control over my schedule. And so a few months before finishing fellowship training, I decided I wanted to use that time to really explore things in the world that I hadn't, and as many of us are, we're pretty defined by our interest in medicine. And so I, for lack of a more eloquent or magical way of describing it, started to do a bunch of internet searching as to humanitarian surgical opportunities that may be out there.

The American College of Surgeons had a link on their website for humanitarian missions and surgical interests, and you filled out a short questionnaire as to what your interests were, what your financial limitations were, what your time frame availability was, what your subspecialty or training area of interest was, and then they spit out a couple of NGOs that may benefit from your interest or your expertise. And through that process, I learned of an NGO in Israel and in Palestine called the Palestine Children's Relief Fund, PCRF. And so I contacted them, and that's led to where I am today. You know, it was an inherent interest, but one at that stage in my life I had no idea the profound and significant experiences and gifts that it would provide me over the years.

Margaux: That sounds like you had a great opportunity to get connected with various different organizations that would allow you to do this global health work. I hear and I read a lot about different opportunities for medical students, and one of the things and what I want to ask you is, how do you look at a program or an opportunity and decide or know if it's an opportunity that will be impactful for that community in a meaningful way versus a experience that is more impactful just for the person, like the student going on it?

Dr. Husain: Well, I'd suggest to you, and maybe I'm a bit naively optimistic about that, but any opportunity is going to likely check both of those boxes. I think the way we have evolved in terms of our world becoming smaller in so many ways and opportunities becoming so much more prevalent regarding your ability to expand your horizons and actually broaden your ability to share your knowledge and your healthcare delivery that you're learning as medical students. You can never start too early. Any project, any initiative, any visit has benefits all the way around. You may not necessarily be directly providing care to patients or citizens of the region you go to, but them seeing your interest, learning about you, having social dialogue with you, gaining some insights about your background, all of those things I think are part of the humanitarian power of global health outside of just the delivery of healthcare.

Clearly, for the visiting medical student or young physician, it's also very impactful because it gives you such perspective that really no classroom environment, clinical rotation environment, textbook reading environment is going to provide for you. Embarrassingly, I'd suggest to you that over the years, every year when I go on these trips and we do operations abroad, I come back with a lot of kind of utopic thoughts in my mind about how I'm going to change my perspective about approaching healthcare here in the U.S. and how I may change the things that get me excited, or get me frustrated, or get me stressed and have a more broad-based understanding of really the gifts that we have here about how we deliver healthcare. And like I said, embarrassingly, that probably lasts about a month or two, and then I'm back into my grind. And in a way, as the months then evolve and I get closer to my next trip, I almost have this like aching urgency to go back and hit reset. And so whether it be early in your career, whether it be later in your career, whether you're just starting, or whether you're in your 10th or 11th year of doing it, the benefits are there no matter what your environment is.

Harjit: Dr. Husain, I think that what you said there was just such an important key. I've done one global medicine trip, and I really understood the value that community-based, participatory collaborations/partnerships are. And I think that that's one of the most powerful things that I've learned from global medicine, that you really need to create those connections, create those relationships, have a community, build that infrastructure as you mentioned.

Dr. Husain: You know, healthcare is one of those things that transcends everything. It transcends race, gender, religion, color, culture, age, and being able to deliver healthcare and being able to receive healthcare regardless of all those significant levels of differences that we have in terms of people around the world is a pretty unifying mission. I wouldn't go as far as saying if I do an operation on a newborn, who comes to Primary Children's from St. George is less impactful on my life than doing an operation on a newborn in the Gaza Strip. But I will say that if I'm being truthful, that it impacts me in a different way, because I know the limited resources they have there and what the reality is of their life there without teams like ours traveling there.

So to give you some data, about 92% of babies born in the world with a congenital heart defect, where surgical intervention is required, never receive that operation. And so to be able to somehow, in some way, shape, or form, bring that number down means a lot to me, and I think it means a lot to people like me. And there are several like me, who do these types of things. The relationships you form with local people over the years. I can tell you in the last 24 hours I've had some people from Israel and Palestine WhatsApp me to make sure that we're okay here after the earthquake. It's truly a gift of relationships. It's truly a gift of trying to narrow that data-driven understanding of disparity. It's truly the ability to allow people from very different backgrounds to come together, even if it's only for a week or 10 days.

Leen: So I've been to the West Bank, and I constantly get feedback from people over there over the disparities in healthcare and how it's impossible to change the system. And, you know, bringing in new specialties is just going to cause more chaos. And there's a cultural misunderstanding of when to give, you know, antibiotics for instance versus other treatments. How did you navigate that? How did you . . . and especially, in the Gaza Strip, when you're surrounded by chaos? When I've tried to find trips to Gaza, people would actually tell me, they'll say, "Oh, no. You can't do it because it's not like here, where you're just doing a simple procedure in a perfect, semi-perfect environment. Over there, there's bombs going off." So how did you navigate that chaos?

Dr. Husain: What you're describing is all true, and I don't mean to undervalue or diminish the struggles and the challenges, not only for the people there locally but for a team like ours to go there. But maybe in a lighthearted way, one of the ways I would answer that is when you take 12 to 14 people to a foreign country, all of a sudden you're best friends. It's like you're going to camp together. It brings out the best of everyone in that team. And everyone's willing to understand that it may take 8 or 10 hours to get through a checkpoint. You may have to put in a central line using your iPhone light because you don't have power. You may have to start your second operation of the day at 5 p.m. or 6 p.m. and it may go till midnight. You may feel really tired. Silly things, like that special kind of creamer you have in your coffee every morning, may just not be available. All those things just don't seem to bother you as much.

There are plenty of amazing people in this world, who do things, and you sit back and you go, "How did they ever do that?" And I think the common answer to it is, for all of us, we have it in us. It's not some unique trait or talent or some level of intellect that's required. It's just kind of a relentless desire to get there. And I'm sure each one of you could think about something in your life that really matters to you. And you sometimes take routes and make sacrifices and are relentless to get there because it just really matters to you. And for me, this does really matter. And so it hasn't always been smooth. We've made some mistakes about being a little short-sighted in equipment or medicines we bring. We have to adjust plans all the time, moment to moment.

But, now, kind of entering the ninth, tenth trip that we've made, we've gotten a lot better at it. We can predict certain things, and we can be better prepared. And we can do more operations, and we can feel better about the outcomes that we're having. And we can feel more confident about how healthy the kids are when we leave. And so it's a process, but it's something that I think not only myself but a lot of the folks that have joined me on these trips have valued it to the point that you just make sure, you feel as if you're going to get there no matter what road and route and challenges you have to take and avoid to get there.

Harjit: I think you bring up a really good point, building this teamwork/community with the people that you're working with. I think as doctors we're taught a lot of like this is the procedure and these are the steps you have to take, but it seems like you have to adapt a lot and use your own mind and be a critical thinker to change things depending on the resources you have. How has that been to navigate? Do you feel like it's pushed you to become a better physician? It's pushed you to think outside the box?

Dr. Husain: Yeah, most certainly. You know, the field of pediatric heart surgery is somewhat unique and I'm sure I'm biased, but it requires a very broad-based multidisciplinary team. We can do a perfect operation, but if anesthesia isn't quite right, or the person running the cardiopulmonary bypass machine isn't quite right, or we struggle with some care in the ICU in the post-operative setting, things can get derailed pretty quickly. And so the need for everyone on the team to be agile and to think outside the box and be prepared for having to deal with issues, where things they're normally used to having at their disposal aren't there is very true. I do think it makes you a better physician, but I would suggest, again, maybe a bit hokey, it makes you a better person, because then you come back here and you have all those things. You have all those tools and you have all those amenities. And so it's not as if you have to repeat some of those odd ways that you accomplish what you needed to accomplish.

And in that sense, I think it makes you a better person, because it gives you, as I said, more perspective, a little more gratitude. You know, we all in jest use this phrase, "Oh, that's a first-world problem." You know, I think when you've experienced third-world problems, it really does feel like it's a first-world problem. So, yes, we've had to do many adjustments, whether it be dealing with power outages and generator use, whether it be dealing with instruments, and for us, cannulas that we use to put people on bypass that aren't quite ideal, whether it be having to make intellectual judgments about certain things because we can't get lab values, whether it be that we have to rely more on physical exam because we can't get perfect x-rays or CT scans. It does really force you to use some of the basic tenets and skills that we're all taught, but often time, we let go of because we have other means technologically and other platforms to still complete our jobs. It requires us to be a little bit more organic, a little bit more natural in how you're taking care of certain challenges you face.

Margaux: You've talked a lot about just how meaningful it is to go and be there and develop these relationships, not only with the people that you're with but also with the people in the community that you're serving, and I'm just curious since we're a very narrative based on this podcast if there was a particular case or interaction with a family that stands out as impactful for you?

Dr. Husain: You know, I haven't really said this yet. One of the most important principles that I followed for me, personally, is, I've tried very hard not to think too much about the political challenges that that region of the world faces because not living there, I feel really ill-prepared to be able to authentically discuss the challenges that go on, on a higher leadership, administrative, governmental level. So I think about the people. And, you know, I wouldn't say there's one story, but there's themes. You know, a lot of these children are parts of families that only have one parent, oftentimes, only a mother. They've lost their father because of one reason or another. A lot of times in the hospital setting, even though it's within the Gaza Strip, only one care provider can come with them, and so two or three other children are far away and really struggling in terms of who's going to provide care for them.

We bring little toys, little knick-knacks all the time. So I think about my 7-year-old, who's outgrown them now, but if I went home this evening and dug through his closets, I bet you I could find 50 Matchbox cars. You give, you know, a 2-year-old or 3-year-old boy there a Matchbox car and it's gold, and the immense amount of happiness that it brings. Or, you know, one of the cardiologists that I've gone over with every year now will take with him four or five soccer balls that haven't been pumped with air yet, and he has a little handheld air pump. And on the last day, he'll pump up all these soccer balls, you know, outside the hospital grounds to just kind of give them to kids and just the sheer joy that you see. It's the fact that little things matter so much to people in different parts of the world that we take for granted.

And it's the fact that in spite of their economic woes, in spite of some of the social challenges and oppression that they face, you'll do an operation on a child, and it's pretty common that the next day that family will bring a little bag of chocolates that somehow they purchased from some store nearby and they want to give it to the healthcare team. And they insist that you each have one and share one in front of them so that they feel as if their gratitude is acknowledged. Yeah, I would say those types of things are things that will stay etched in the memories of all of us that have gone on these trips. And I think anybody who's participated in a humanitarian medical global initiative will have similar stories. Every act matters. As human beings, we want, you know . . . I think sometimes we get handcuffed by wanting the big picture to be really big, and it's the little things that make the big picture.

Again, I say a lot of this with humility, but when we started, you know, doing a case or two, over the course of a week, was a big deal. But you'd say, "Wow. Am I really participating in global health if I did two cases?" And, you know, we look back on our data now, and I think we're up to about 145 pump cases we've done in Palestine and Israel. And so it just takes time, but they're building blocks.

I know that the thoughts of many, right now, are pretty overwhelmed by the coronavirus. And in a sad way, it's also yet another example of the global spread of medicine in an unfortunate way, where one individual, one infected source spreads dramatically. Good can happen that way as well, taking care of one child, creating a relationship with one pediatric cardiologist, gaining the confidence of one hospital in the West Bank affords you to have a better relationship with, perhaps, the Israeli government to get a permit to get into Gaza to then meet another set of hospital administrators and it spreads, it spreads.

Margaux: I think it's really relevant that you say this now to especially while we as medical students have been suspended from clinical duties. And as fourth years, we're two months away from becoming doctors. You know, most of us have had the training to start internship and having been suspended from clinical duties in this time of uncertainty, in this time when healthcare providers will undoubtedly be called to the frontlines to help with this pandemic, it feels to me, and I think the other, Harjit and Leen as well, like, we're not doing anything, and like, we're just sitting on our hands at home. But I like that you said every little act accounts. And I think that it's . . . it's hard for me to feel and recognize, but like staying home and staying healthy, doing this podcast remotely like we are actually is contributing in some small way. So it helps bring me back to that right now, and I think that many students are probably feeling that.

Dr. Husain: No, I mean I can't imagine what it's like. I'm sure it's a frustrating time for you all. I'm sure you feel very helpless. This should be a time where you're approaching the finish line, and you cross and you break that tape and you jump up and down and everyone's excited. And it should be happy. And it's a huge accomplishment, and it's somewhat challenging to navigate that emotionally.

You know, I'm not saying that what I'm about to share is right, it's just a personal perspective. I do have significant anxieties, as I'm sure all of you do, about what the next two, three, four, five months are going to bring for this country. I think that the reality and at times of hardship and uncertainty, I'd like to be a pretty unemotional, reality-driven person. And the reality is, right now, entities like the University have a responsibility to protect you all and have a responsibility to navigate the roads you travel until you receive that diploma and certificate.

And I think their intentions in terms of what they've decided regarding your role in healthcare, right now, are all with good intent. I would suggest to you all that you will be immensely needed come July 1. And so, although there may be some philosophical mistruths to this, the fact that we're doing everything to keep you all healthy so that come July 1, we can really use your talents and skill sets is true. And we look forward to having you join the workforce.

Harjit: Yeah, thank you so much, Dr. Husain, for that perspective. And I think that's kind of the one that I've been holding that even me being at home, and being healthy, and being prepared is me contributing. I really want to go back to this point that you just mentioned a couple of minutes ago about how we're all connected and how one individual can either make a positive or a negative impact. I don't think we come into medicine thinking we're all a part of global medicine. But one thing I've learned through global medicine is that every single one of us is a part of it if we're here or we go abroad. Kind of in that thought, how do you feel like we as students can be aware of healthcare worldwide? How can we try to stay connected and stay together with this field of global medicine and global health?

Dr. Husain: You know, we hear this all the time, knowledge is powerful. You know, understanding how healthcare is delivered in different parts of the world, whether it be, what are the economic components of how it's delivered, whether it be, what are some of the technological components of how it's delivered? And as you all start to embark upon more specialized training in different areas of medicine, it's going to be but natural that your interest is likely going to be in that field of medicine. So, for example, if you're going to go into obstetrics, you know, what are the disparities in terms of how fetal diagnoses are made of children that may have congenital defects? Why are there, perhaps, differences in the rates of different methods of delivery across the world? What impact does prenatal care have upon outcomes for both mother and child? I'm nowhere near an obstetrician, and I'm just, kind of, making this up on the fly.

You know, you can pick whatever area of medicine you want, and without having visited a third world country, you can start to become pretty knowledgeable about how that area of medicine is delivered around the world. And what are some of the potential disparities of that delivery of medicine? I think that's pretty powerful and that's global health without leaving your home town. And I think you raise a really good point. Some of us will have the opportunity to go abroad and deliver healthcare. And some of us may not, for whatever reason, and it may not be because of a lack of interest to do so but that doesn't alter your ability to become involved with global health.

I've got two surgical partners in my group, right now. In my book, they participated in global health because they covered for me while I was gone. Your ability to get involved with global health, whether it be to educate yourself, whether it be to gain a more active interest as to what's going on around the world, whether it be to define disparity in a more tangible way for yourself, whether it be to support activities that people are doing overseas, financially support them, support them in terms of being involved with initiatives that are allowing for those activities to occur, or just covering a partner of yours that's going abroad, I think all that's global health.

Margaux: Earlier, you mentioned, and we, kind of, talked about how your motivation for going to Gaza and the West Bank, and the sort of, area of chaos and low resource, was because even if you could make a dent in one number, change one patient's life that made enough of a difference. And so, when I'm thinking of the pandemic now, and all the healthcare providers, who are on the frontlines, that can be a very scary decision, you know, when you're about to head into a patient room and there might not be the appropriate PPE, right now. How do you . . . or do you have any advice, or how would you talk someone through that, like, building the courage to put yourself in that situation?

Dr. Husain: I think what's happening currently in our world is unprecedented. It changes every day. Every healthcare provider is different in terms of what they feel their responsibility is, and I think we should be respectful of that. The decisions that are being made in Italy, right now, in regards to which patients receive care and which don't? Do healthcare providers have more of a priority to receive healthcare than non-health care providers? It's unfathomable to have to put yourself in the shoes of people that are having to make those decisions.

Here at Primary Children's, I'm part of a team that is genuinely struggling with, "How do we define an urgent case versus an elective case?" And how do we tell a mother or a child, who needs congenital heart surgery that it's going to be okay if we wait two or three months? Because instinctually, we think it should be okay, even though we don't know.

The issue of going into a patient's room without PPE, I think that's an individual decision. You're going to have physicians that are going to be of the mindset that their priority for their responsibility as a healthcare provider precedes everything, and they're going to go in that room and care for that patient. And there are going to be other healthcare providers that are going to feel as if, "We'll do our very best, but unless we take that precaution, we take on risks that are going to remove us from being able to take care of other patients and it's going to detract in our ability on a more broad basis to deliver care." And I don't know, which is right.

Right now, as a medical community, and quite frankly, as a society, we have to suspend judgment. We have to follow basic protocols. We have to band together in terms of understanding what our social and moral responsibilities are. If there's one challenging silver lining gift of this pandemic is that hopefully, it will bring the world a little closer together.

Leen: I love how you said that. For the last couple of days, I've been ranting about the idea of quarantine isn't supposed to be part of an individualistic culture but a communal one and a collective one because that is the only way we can actually defeat, you know, this virus, and we can come together as a society. It just doesn't make sense in my brain if, you know, you're in your house, you're in the safety of your house, you don't have the virus, but your neighbor has the virus and the virus is still there, right? Unless we come together, and we're able to help each other out through this, then we'll be able to get through this. And I apply this to the virus, but I feel like this applies to a majority of tough situations that happen globally on a daily basis. Especially, when it comes to medicine, we have to be able to communicate that.

Dr. Husain: I couldn't agree more. And I think with this particular scenario, we have to hit reset every day. And it's not only reset in terms of the plans that we make moving forward, but it's reset in terms of not judging mistakes that may have been made in the past. We're wasting our time if we're continuing dialogue regarding a decision that should have been made a week ago that may or may not have been made, or a decision that went in a direction of success versus a direction of failure. Tomorrow is going to be a new day. We have to hit reset and decide how are we going to approach this day in terms of trying to do the very best we can ensure to, whether it be flatten the curve, or limit the impact, or help protect one another, whatever verbiage you want to use.

Harjit: Thank you so much. Dr. Husain. I think we're going to wrap up pretty soon. And I want to leave off with two questions, the first is there anything else you wanted to add to this podcast? And the second one that we often ask all of our interviewers and is, maybe, a big question, what is the legacy that you want to leave behind on this world?

Dr. Husain: So I'm going to be pretty open with you. I've just turned 50 this year, and for whatever reason, that number really hit me. This concept of what you leave behind and legacy on a very private level has been ruminating in my mind and racing in my thoughts. And I think one of the things that I've concluded for myself, personally, is that it's really short-sighted and somewhat impossible to define a legacy while you're still here on the earth. Every day, all that you do, the successes you have, the mistakes you made, the things you learn, the impact you have on each and every person that comes across you will in, an additive way, create your legacy.

So rather than worrying about defining what one wants their legacy to be and then coming up with a strategy of how to achieve that, I would suggest to you, we don't really know how much longer we're going to be on this earth, and people are going to define our legacy after we're gone. So we're not going to have much of an ability to create the narrative of what our legacy was. Really, the best way to control whatever that legacy ends up being defined as by someone else is to do everything you can every day to be a contributor, to make people smile, to do the right thing, to understand that we all have fallacies and to forgive, to be critical of ourselves.

We're so fortunate to be in healthcare. We have an immediate bridge to doing good, immediate access to doing good, and so do the very best you can with that gift and that platform, and your legacy will create itself.

Harjit: Thank you so much. That was so well said, and I think allows us to think a lot about what that term means, and how we can add to and contribute to medicine. I want to reiterate, kind of, what I started with that, I think you so beautifully highlighted, throughout this whole podcast, is we are all connected. Every one of us matters. The action that each one us takes matters and really contributes to global health and global medicine. And I really want to thank you for being vulnerable and sharing your stories with us.

Dr. Husain: Well, I appreciate the time. It was a great experience and keep doing what the three of you are doing because I'm sure it's really impacting more people than you know.

Harjit: Well, we want to thank our listeners for listening. You can find us on @bundleofhers on Instagram. Please let us know your thoughts about this podcast about global medicine. Any feedback you have, any critiques you have. And we want to again thank Dr. Husain and thank him for all that he's done for everyone. Thank you so much.