S7E17: Health Policy’s Role in Global Medicine and Future Practices

Hạ: As you all know, we had to rechange this recording because my phone underwent a phone transplant. It was not really fun.

Alizah: Wait. So what did they take out and put back in?

Hạ: I don't know. Something about the hardware. There were kernel issues, whatnot. I don't understand the phone thing. This is why there are Apple Genius people out there.

Anyway, hello, dear listeners. I am in the virtual studio. And then we have a very special guest who you may have actually heard before.

Siale: Yeah. Hi, everyone. My name is Siale. I am a fourth-year out of the University of Utah. I was originally classmates with Hạ, but I'm excited to be back with the Bundles.

Hạ: But one of the fun new updates is that Siale has matched in internal medicine at the University of Washington. Woo-hoo.

Siale: Finally got my first job at 30.

Hạ: What a vibe. And so I think now being a fourth year, you've gotten to do a lot of really cool things. There was a trip that you recently did, right, Siale?

Siale: Yeah, fourth year is the best because someone told me . . . they're like, "If you see a picture of a fourth-year, they're most likely on a beach somewhere or something like that." So fourth year is great.

But I recently just got back from a trip to Tonga, where my dad is from. I did a global health elective. I was out there for about four weeks and was lucky enough to spend some time learning from the doctors in Tonga for a month.

Hạ: And I think this is actually a really good segue for us to introduce our conversation topic, which is that for this episode, I really wanted to focus on health policy. And this is why Siale is a guest in this episode. She got her Master's of Public Health. She's also just a cool person in general, so we always benefit from getting Siale's insights.

With all of this, Alizah, talk a little bit to the listeners about why having a conversation about health policy feels important to you.

Alizah: All right. So this is our disclaimer that all thoughts and ideas are solely ours that do not represent or are in no way a reflection of our schools or respective places of work.

I think health policy is something I've really begun to have an interest in because I think when I started medical school all of two years ago, not very long ago, I was like, "Oh, medicine. This is where you impact change." But I think as you become more familiar, you realize how much policy and I think systems are involved in impacting that change. And I think that's really kind of the juncture of where health policy meets.

As Siale has been on her rotation in Tonga, it's been phenomenal to just see it through an Instagram lens, which I know isn't always the most detailed or maybe has a filter on it, so to speak. But it has really been so meaningful to see that.

Hạ: As a part of medicine, one of the things that I found that I've been forced to really explore and to really think about a bit more deeply, similar to you, Alizah, is thinking about health policy.

My introduction to health policy was through the Population Health elective. I think I had heard about it and I knew about it as a theory, but I wasn't really interested in it, if I'm going to be real. I cared a lot about community health, I cared a lot about working in underserved communities, but I'm a bit of a Scrooge when it comes to legislative processes and thinking about policies in general. And so I completely ignored it. Then I did Population Health and I realized, "Wait, this does have impact."

Thinking with all of that in mind, just to start off the convo, I'd love to hear from both of you, maybe to start with Siale about your introduction a bit more to health policy and how you feel about it based on your experiences.

Siale: Yeah, I think I'm the same as Hạ. I was never interested in it. And I also just had a . . . I don't know if I'd say poor attitude, but I think I felt like a lot of my communities have been hurt by policy, and so it's a reason for me not to engage in it.

Also took the Population Health pathway with Hạ, but really where this all started was during the pandemic. The Utah legislatures were looking for a place to take funding from, and one of the first places they went was the state-run health clinics here in Utah.

And so some of the local Pacific Islander organizations invited students to lobby, basically to write letters to state reps about why that's a bad idea.

And during the pandemic, Pacific Islanders and Hispanics were two or three times more likely, one, to be infected with COVID-19, but then to be hospitalized and to die from it. So it was crazy stats.

So a state-run health clinic background that's a safety net clinic for those who are uninsured or those with maybe Medicaid or other public health insurance, they serve a lot of the people of color in Utah. In my mind, this didn't make sense that the people that were being hurt the most were going to lose resources, a really important thing for them.

And so I became very passionate about, "Yeah, this doesn't make any sense. I'm going to write my local state reps," and sent these long letters to them. And then to my surprise, two of them invited me for a phone call. I'd never done anything like that and I was like, "Yeah, I'm going to tell them how wrong they are and I'm going to stop this. I'm going to keep the clinics open." I was so fired up about it.

And then did the phone calls and felt like an idiot after both of them because I realized I didn't know how policymakers think, and it was really hard. They were asking me a lot of questions I just couldn't answer.

Then started to think about population health and then was starting to see how it's all related. I was like, "Oh, my gosh, this stuff is actually really important. And when I go to talk to a policymaker, I've got to be better prepared."

After this conversation, they ended up closing the clinics. And I think I took that kind of personally, like it was my fault, even though I think the legislators had already made up their mind far before I ever had a conversation with them. But I took it kind of personally.

And then just seeing how it was all connected, I felt like I could be a better advocate for my community if I tried to learn more about how things work. You can't change a system that you don't understand, and so I think the first step for me was . . . No one has ever taught me a lot of this, and yeah, I took basic U.S. history and government in high school, but I really didn't understand what policymakers care about.

And as much as I'd love to think they care about my stories about my family that I was trying to share and my community members, that wasn't enough. And I think those are important pieces, but understanding how to better talk to them, that was something I was interested in, which led me down this path of "How should I look at things during third year?" I was like, "I think I just need more time. I need to step away from medicine and I need to really understand the bigger picture of this all."

And so that's what pushed me to leave for a year and to learn more about it. So I don't consider myself a policy guru. I'm very new in this space. But it's something that I feel is important, because no one teaches you that in medical school, like Alizah was saying.

You're like, "I go into medicine because I want to help people," and then you realize how limited you kind of are in a way because you're working within a system and you feel like you can only do so much. And so better understanding how that system works so you know how to make changes to it for the better.

Alizah: I love that. It should be noted the humility in that response, right? I don't know. It's hard. And I think health policy kind of does have that bitter taste, as you mentioned, when you're assessing or exposed to the health disparities in the community and ensuring that there's access to high-quality care, and the wellbeing of entire populations.

Having those considerations taken into account and then advocating for these things, it can be difficult, but I'm really appreciative of how you mentioned becoming a better advocate. I think that's phenomenal, and that's a lesson I need to learn and take away from this.

Hạ: And it's so interesting because I feel like now as I go through residency, there are just so many moments where I'm sitting there thinking about things that I want to change, and I realize that a lot of times the interventions that we have to do are actually on a very policy level.

I might feel this very deeply also as a pediatrician, because a lot of our health and a lot of our interventions are community-based and school-based. For instance, just today, I was talking about substance use disorder and prevention of it for adolescents, and a lot of it is actually based in the school.

So, as healthcare providers, we actually don't have as much weight in being able to do those interventions, but what we do have weight for is to do the policy changes and to really campaign for better funding for schools to implement these programs across all equity lines, not just really bougie, rich schools.

It is something that I've reflected a lot on, is that I can't just ignore something just because I hate the elitism or the difficulty of moving with it. You sometimes need to have some knowledge.

And I'm curious, Siale, understanding a little bit more about how this carried through for you when you were in Tonga.

Siale: Any time you take a global health trip as a medical student, and I think even in the future as a provider, you're just like, "Can I actually be helpful in this system that I don't really understand? What can I do?"

And so I think any time you're approaching a global health elective or experience, you have to be very open-minded in that, "Maybe all I do at the end of the day is I just watch and I just learn about how the system works."

Background, and I've said this before on here, but I identify as Tongan and then also Hispanic. My dad is from Tonga, grew up there, and so I've always had this desire to be able to go back there and to hopefully be helpful and be a tool and support where it's needed.

And then I kind of felt like, "They don't really want my help and maybe I'm not . . ." I don't know. And so I went back and forth for a long time about whether or not I should do this elective, but I decided I would go and just take whatever was handed to me, and if they didn't want me to do much, we wouldn't do anything and just learn about the system.

Especially as a medical student, you don't know how much or how little you can hands-on do, but I went in with the mind of, "I'm going to learn as much as I can about the system. I'm going to ask people questions about things that maybe other people don't care about." And it was really insightful and impactful.

But just some basic background about how Tonga's healthcare system is, it's all publicly funded, which means the government pays for healthcare in Tonga for all of its citizens.

In the U.S. we have an income level. "You have to make below this in order to qualify for Medicaid." And then for Medicare, we know you have to be this old and you basically pay into it all your life so that when you turn 65, then you're eligible.

But in Tonga, everyone's healthcare is paid for by the government, which is lovely and I think it should be like that everywhere. But in a small place like Tonga, that can come with . . . They only have so much money, and so it's nice that they pay for everything. But because they pay for everything, they're very limited in what they can do and what medications they have available to them.

And so understanding that you're working within the system that is free, it's essentially free, but it can really change what resources you have available to treat your patients.

Then they don't have the wide variety of sub-specialists that we have here, and so understanding that too. General internal medicine doctors, they're doing everything. They're like what you think of in the U.S. as family medicine docs who live in rural areas that they're just kind of doing it all. It's similar. The GPs there do a lot of the work, and there's a lot of burnout.

I think I could go on about a billion things that I learned from there, but I think the biggest thing going into this elective was to understand the system and then see examples of policy.

So I did two weeks on the medical floor, and then I did two weeks with the public health group. And so both of them were great experiences and learning about how things work, what they have available to them. And then just how innovative people are with how little they have, I think, was one of the biggest takeaways I took from it.

Alizah: I just think also being Tongan . . . And I consider Siale and I to go way back. I mean, I've always seen how when she applied to medical school and those things, to see her also go to Tonga and watch these systems in place was, of course, I said impactful before, but I think it really opened my eyes into how systems are different, but they're also very similar in the sense that they're both structures and they're both institutions.

I also have this same dream of going back and offering help if they want my help. Or do they? I don't know. It's scary and it can be intimidating when these structures seem bigger than you or foreign to you, as Siale was saying.

And so I guess my question for all of us is, of course, you can approach this and learn more and become more interested, but when you are an everyday type of person . . . I feel like an everyday type of person outside of medical school, even. How would you start to get into this? How would you start to learn about health policy?

Siale: There's a quote, and I'm going to butcher it because I don't have it right off the top of my head, but it's something like, "Start where you are, use what you have, and do what you can." I can't even remember who exactly said that.

And I think that's the big thing that's really intimidating about health policy or just thinking about systems in general. You're like, "I am just one person in this big problem. How can I actually change it?" And I think knowing it's okay if your impact is only small. Helping one person is still one person helped. And so I think when you can frame it as, "I am just going to do what I can."

So even as a medical student, I can write a letter and I can talk to a legislature. And maybe I'm not going to change their minds, but at least I know I went to bat for my community when they needed it. I can show up to a community event or I can do something.

I feel like this happens with med students or pre-meds. They think they're beyond taking blood pressures or they're beyond checking someone's blood sugar or whatever. No one is beyond any task.

When you can just start with where you are and just doing very basic things, those things are I think . . . One, they can make an impact even if it's a small impact, and then, two, that's how you build trust within a community and within different spaces that I think most people want to serve when they try to do this work.

Hạ: One of the things that I try to ground myself on is, really, people and their stories and their experiences and their feedback. And I feel that a lot of times we go into something and we want to come in hot, but there's such a utility in just coming and going like, "I have no idea what's going on. You all have done so much of the community work and understand these perspectives a lot more and understand what is the needs assessment, what is what the community needs for policy changes. I'm just here to listen and to understand and then funnel it into allowing me to leverage what I'm able to do to do it."

And I also sometimes wonder if it's just because child of immigrants, woman of color, I sometimes feel the weight of the world on me and that I have to do everything.

But one of the things I've learned is it's most impactful when you kind of realize what your strengths are and what you're able to bring to the table, and then you take that feedback from other people to support them.

That's kind of my take on it. But again, also, I'm not the most health-policy-prone person, but that's what I think about when I do community organizing or trying to engage in creating systemic-level change-ish.

Alizah: I love that. I think it does get overwhelming. And I don't know why, but when I think of health policy, sometimes I think, "Oh, I need to go down to the State Capitol. I'm going to have to go sit in one of those rooms and prepare before the board." And I'm just like, "I don't know anything."

And I'm still trying to figure out anion gaps. I keep coming back to that because I don't know. But I'm like, "They do not want to hear from me. I am nobody."

It's not that complex and it's not that deep. Just get out there. And I think work and service . . . Like Siale was kind of mentioning and as Hạ was saying, you're not beyond a task. Get into it. And it does seem big, but you can you can manage. I think that's a great place to begin, and I'm excited to get that advice from you both.

Siale: Yeah, I think like anything, it's just showing up and stuff. No one really expects you to be able to walk in and change everyone's mind in the very first second that you get in there. But I think doing what you can and being genuine and authentic, I think that's one of the most important parts about the whole thing.

Yeah, there's a lot of preparation that goes into it, but I think people can feel, when you talk, when you're really passionate about something and you really care about something. You would hope policymakers notice those things.

Someone asked me, "What are you going to do when you finish this program and go into medicine?" And honestly, policy stuff is probably going to be on hold for a while in my life. But whatever you do, whether you're a doctor, anyone, if something impacts you, you should tell a policymaker how it impacts you and your family.

And as a doctor, we can talk to how it impacts our patients. I think that's the privilege of going into medicine, is people will listen to us because you have an MD or DO or whatever behind your name. And even though that's really icky, there is power in that in knowing, "I went through this because I want to help my community."

And so using that to your advantage of knowing, "I take care of patients day in and day out and I see how this impacts them." Policymakers really should listen because you're on the grind every day, day in, day out, interacting with people that these policies impact. And so I would hope and I think a lot of them will listen just because of the title that we're so privileged to have when we go through medicine.

Hạ: It's so weird because I'm always like, "Ugh, I don't like the MD," but then I also realize the MD actually helps give me some weight sometimes in doing things. It's that tricky balance.

I feel like I'm in so many convos with people talking about navigating systems and when is the moment when you want to just leave the system, but then you're always filling this fear, "Maybe I need to be in it to gain the knowledge I have to actually create the change," and all of that.

And I vacillate back and forth, as anyone who listens to this podcast probably now. Sometimes I'm like, "Burn it all down." And then sometimes I'm like, "I guess we have to be here to change things."

Siale: Yeah. I feel like I struggle with that tension too. When you come from a community that's been hurt by systems, the last thing you want to do is feel like you betrayed your community by playing into the system.

I think the other thing about policy, though, is you don't know how to play the system if you don't understand how the system works. And so you don't know how to burn it down until you figure out the ins and outs of it.

And so I think that's the other impactful thing that comes with policy, is if I know how these things work, then maybe I can actually change it and maybe I can actually burn it down one day and start with something better. But I feel like I go through that same internal tension every single day.

Alizah: I'm on the optimistic side today. It will probably change tomorrow once I dive deep into renal for Step dedicated. But one thing that I've learned and has kind of changed my perspective about health policy and being in the system that is not necessarily fond of the communities I come from is I will be in rooms that many people from my community may never be in, and I will be in rooms that people from the system will never be in.

And so I think just the idea of your existence as advocacy, for me, was groundbreaking. I don't have to do a ton, even though I feel like I might or need to or should. Me just existing in this environment is advocacy also in a way. I don't know how that sits with you guys, but . . .

Hạ: I feel that is something that I do think a lot about, is resistance just by presence. Sometimes it comes back to that thing that I said earlier about having to always feel like you have to do the most, but sometimes just existing is doing the most itself because the system isn't built for you to just exist in it.

Siale: Yeah. And I think on that note, just one thing I want to say is I think policy can be a really draining space. I think, in my mind, I have one idea of perfect or ideal, and knowing it's going to take a long time to get there, I think it can be really frustrating and you can get really down on yourself. And so just existing or knowing, "I'm in the fight. Even if I can't change it today, maybe I can get one step closer to where I want to be."

That term "perfect is the enemy of better" or whatever, I think that's the other thing when you enter policy and community work. We're always working towards the ideal, but we can't be so hard on ourselves.

If we can't get to the ideal tomorrow and, like you said, just existing within a space and showing up for your community when they need help, those are the things that I actually think are the most impactful in the long run.

Hạ: Thank you so much for sharing all of this, Siale. Sometimes I feel like we just need a five-part series with just you because I feel like there's still so much more I want to ask about your experiences at Tonga, what you've learned from policy, and all of that. But alas, I need to check on my pizza that might be burning in the oven right now.

But before we do close up, I'd love for you, Alizah and Siale, to share any last few thoughts that you have or things that you really want to leave or things that you feel like you weren't able to say that you want to tell to our listeners.

Alizah: We'll save the best for last. We know Siale's got this. But I guess I just wanted to say that it's worth it. The work you put in to change, even if it's not noticeable, or just listening to, as Hạ said, these patients' stories or taking the time to listen to anybody or express how you feel, that makes a difference. And even if you aren't able to see the fruits of your labors, you are planting seeds that maybe a few generations later, there will be something to show for it.

Siale: Yeah. I feel like I don't have any big thing. There's probably a lot of stuff I'd like to say. But I think that quote, and I'm sorry I'm butchering it, but "start where you are, do what you can with what you have." I think just knowing it's okay if you don't change everything today, but knowing that you fight and you're doing what you can, at least you know you can go to bed saying, "I fought for my communities." And that's more than enough.

When you have a community, you'll keep working together to be towards the perfect or the ideal. But keep fighting.

Hạ: Yeah. I love all of that, Alizah and Siale. And I do think that's the thing that I always come back on, is you can choose to do whichever route you can figure out policy. You can stay in the system, you can stay out of the system, but as long as you always ground it in what is most important to you and your core beliefs and values, I'm hopeful that you will find fulfillment and change in the way that you want to find change.

So thank you so much for listening. Feel free to follow us on Instagram. Listen to us wherever you podcast. It's been such a solid time, dear listeners. And I hope you all have a great rest of your day. I don't know. The closing is always really hard. I'm really sorry.

Alizah: No, you did great.

Hạ: The pizza is not burning, though, so it's totally fine.