Striving for health equity at home

A few years ago during my undergraduate career, a professor asked me, “What makes primary healthcare services high-quality?” It was a simple question, yet I struggled to answer. I grew up seeking medical care at local community health centers in the Bay Area that are dedicated to serving low-income individuals and families. My own and my family’s experience with the overburdened health centers and overworked healthcare providers skewed my response; I was reminded of the unsatisfactory care we often received. This question, though simple in nature, was profound to me. It led me to developing an understanding of “structural determinants of health”—a term I didn’t know at the time—meaning the forces that produce very different health behaviors, healthcare access and health outcomes among different groups of people.

Much of my experience in the Global Health Sciences master’s program has involved gaining foundational knowledge and advocacy skills to address why and how health inequities occur, including the ways they have impacted my own life. When I was searching for potential capstone projects, I knew I wanted to work with a group that prioritized health equity, cultural humility, and structural determinants. It was an easy decision for me to choose to study with the UCSF Health, Equity, Action, and Leadership (HEAL) Initiative.

HEAL is a two-year global health equity fellowship program that believes transforming people makes it possible to transform systems. It has established partnerships across the world including in California and the Navajo Nation and internationally in Mexico, Haiti, Mali, Liberia, Rwanda, Mawali, Uganda, Nepal and India. The HEAL mission is to train and transform the healthcare workforce and build a community dedicated to serving the underserved. Two things set HEAL apart from other programs: the curriculum and the framework. It is the first fellowship to incorporate structural competency in their curriculum. Structural competency refers to medical providers’ recognition and understanding of upstream factors that drive health disparities. HEAL is also among the first to try to incorporate equity into the way the program works. HEAL fellows include both U.S.-trained physicians, as is typical of many global health fellowships, and – less typical – healthcare workers from international and domestic partner sites. The participants ground the program in a novel interdisciplinary collaboration, where both types of fellows learn from and teach each other.

Given the novelty of HEAL as a global health equity fellowship, my capstone aims to systematically evaluate the experiences of HEAL participants. I am currently doing a qualitative analysis of exit interviews that were conducted at the end of each cohort’s fellowship experience. In particular, I am doing a subset analysis of the experience of fellows who worked in the Navajo Nation for their domestic site rotation.

I chose to focus on the Navajo Nation because it is a prime location to demonstrate the type of work HEAL does. I believe that global health programs must acknowledge the need to work towards equity right here at home. Due to colonialism, historic genocide, environmental destruction of public water sources, and inadequate federal support, the Navajo Nation suffers from some of the worst health outcomes in the United States. The COVID-19 pandemic highlighted some of these vulnerabilities. For example, the 1863 U.S.-led scorched-earth campaign destroyed entire villages and water sources in the Navajo Nation. Today, one in three Navajo lack access to indoor plumbing, making simple tasks like handwashing extremely difficult for a majority for residents. With up to 40% of provider positions vacant, the region also faces a dire need for healthcare workers to serve its population of approximately 332,000 individuals.

Reading about fellows’ challenges with working in the Navajo Nation, as well as their motivations to continue working despite these challenges, has been uplifting and inspiring. As a researcher, I am excited to continue the process of qualitative analysis over the next few weeks. As a former patient of a clinic that HEAL now partners with in California, I feel hopeful. And as a lifelong learner, I realize that the question my undergraduate professor asked me is still difficult for me to answer today. Addressing structural determinants of health and striving for health equity is not easy; however, it’s a pursuit I am willing to take on with HEAL.