Leading the Fight for Global Health Equity - Dr. Sheila Davis, CEO of Partners In Health

Shiv Gaglani: Hi, I'm Shiv Gaglani. One of the most respected players in global health is Partners In Health, an organization rooted in social justice that was founded 35 years ago in Haiti. With a staff of over 19,000, Partners In Health works in impoverished communities in eleven countries to ensure access to quality healthcare. Today, we're delighted to welcome Dr. Sheila Davis, the Chief Executive Officer of Partners In Health, to talk about the organization's current work and how to strengthen the healthcare system before the next pandemic, among other important topics. 

Dr. Davis is a nurse and social justice activist with a long history of serving the poor and marginalized starting with her work with the HIV AIDS community in the 1980s. She was a clinician in the infectious disease clinic at the Massachusetts General Hospital for more than fifteen years, and for the past decade, she has held multiple roles at Partners In Health, including Chief of Ebola Response, Chief of Clinical Operations, and Chief Nursing Officer. So, Sheila, thanks so much for taking the time to be with us today.

Dr. Sheila Davis: Thank you, glad to be here.

Shiv Gaglani: So I'd like to start first with learning more about you and what got you interested in a career in healthcare, and then specifically in nursing?

Dr. Sheila Davis: I never planned on being a nurse. It was in high school, in my senior year, all of a sudden, I just said, 'Oh, I'm gonna go and major in nursing,' which was a shock for everyone, so, it’s unclear where that came from. But it definitely has been an amazing profession, an amazing career, and allowed me to do so many things, which has been rewarding and amazing. I continue to learn every day, and really see that nursing has shown us that it's possible to do so many different things, I think far beyond what I thought was possible at age nineteen.

Shiv Gaglani: It's a tremendous career, and we've fortunately met a number of wonderful nursing leaders, and clinicians on our podcasts, including Elizabeth Iro, who you may know.

Dr. Sheila Davis: Yes 

Shiv Gaglani: She's the Chief Nursing Officer for the WHO, and similar to you, had a career both being a clinician and then becoming a nursing leader, or just leader in general, for a very large and influential health organization. So, one thing that always impresses us about meeting nursing leaders like yourself, is the commitment to lifelong learning and how those careers can evolve. For the nursing students in our audience -- and we have well over 100,000 registered nursing students on the Osmosis platform – I know they would be very interested in hearing about your decision to kind of keep leveling-up and pursuing a Doctor of Nursing Practice, and what value that credential -- or your credentials, in general -- have had on your career progression.

Dr. Sheila Davis: It's not that I had a plan to go from being a bedside nurse to being a CEO of a huge organization, but I think I became involved in the HIV AIDS epidemic in the 80s as a nursing student, and that really shifted my career to be very social justice focused. When I look back on it, every point when I made a decision to change jobs or become a nurse practitioner and then get my doctorate, it was because I was trying to see where I could contribute to this movement I was so passionate about, which was HIV and AIDS and morphed into global health equity. So I think I saw education at each step as a way of getting more skills and more knowledge to be able to contribute to this area that I thought was so critical and I was so passionate about. I think education, or even putting yourself out there to make a decision to go for a job or something is, if you're following your passion, then that makes sense, and you take risks, and you're bold, and you're courageous and you do it. I think for people who are maybe just trying to map out what they want their career to be or where they end up, to me, that wouldn't have worked, because that wasn't my authentic self.

Shiv Gaglani: That's a really, really good point. A common theme we hear from guests like yourself, is that desire and ability to take risks and see those kinds of inflection points in their own careers and the organizations that they lead. I gave a description of Partners In Health and many of our audience will know the organization. I think many of them learned about it through the book, Mountains Beyond Mountains, written by Tracy Kidder about the late Paul Farmer and about its origins in Haiti. Obviously, you guys have grown quite a bit over the past several decades, and you've been a large part of that over the past decade. Can you give us a bit of a sense of the current state of the organization and what your focus areas are?

Dr. Sheila Davis: Obviously, I want to acknowledge the loss of Paul which was such a shock and a personal and professional loss for all of us. I think he changed the movement for global health in a way that is transformational, and I feel very honored that I was able to work so closely with him. We're committed to continuing his legacy long term in really fighting for health as a human right and global health equity as a major movement. 

But now, as you said at the beginning, we work in twelve countries -- because we consider Navajo Nation a sovereign nation -- with nineteen thousand employees. Our focus is really on a few major things. One is advancing the movement for global health equity, and we do that by focusing on health system strengthening. I think what we all learned with COVID, for example, is that without a strong health system, you're not able to respond to a pandemic, natural emergency, etc. and the best way to do that is to build a strong health system, not in the time of an emergency, but to commit to that long term. So that's always been our premise of partnering with the public sector, meaning we don't develop parallel systems, we work with Ministries of Health, we work with local leaders, and work with local governments to ensure that we're long-term impacting the system. 

Another big piece of that is really focusing on building capacity and education, and from the very beginning, Dr. Farmer and colleagues were so committed to ensuring that we're bringing others along with us and we're decreasing reliance on people trained in other places beyond the countries in which we work. So, 99% of those who we work with, or 99% of our staff, are from the countries in which we work. We have over six thousand employees in Haiti. There are very few people who are not from Haiti. Same thing in all of our sites. I think it's different because we're from those communities, we're grounded in those communities, and we look to address the gaps that are in front of us. 

Another big priority of ours is developing the people who are going to be moving this movement forward about global health equity. We do that with bedside training, with medicine residencies, with nurse training, and also with starting a university. University Global Health Equity in Rwanda is another important step that we wanted to take to ensure that we had the highest level of credentialing and providing opportunities for people. 

And then the third kind of immediate priority we have for the next five years is focusing on the needs of women, children, and adolescents. The majority of our work is in providing health care for eight million people around the world, it is focused on women and children because that's who seek health care around the world. So all aspects of maternal child health are what we focus on. In a place like Sierra Leone, which has one of the highest rates of maternal mortality, we're really focused on developing a center of maternal health, a center of maternal excellence to, again, bring the benefits of modern medicine to places that have been disproportionately impacted by injustice. 

Shiv Gaglani: Wow, that's quite a lot. The reason we even call this podcast Raise the Line is the whole thesis of strengthening healthcare systems. COVID revealed that even countries like the US had not invested enough in public health monitoring and response, as we hope to moving forward to prevent the next pandemic. I'm glad you mentioned UGHE (University of Global Health Equity). Before we got on the podcast, I mentioned that they've been a great collaborator of ours. We've provided access to Osmosis to them for some years, and I think they're doing tremendous work to train people in place. There's this movement among US medical schools to create campuses in different rural areas. Like NYIT just created a campus in Arkansas to find students who are from Arkansas, have roots in Arkansas, and potentially after they graduated from medical school, at their Arkansas campus, will stay in Arkansas. 

Dr. Sheila Davis: Yes. 

Shiv Gaglani: Because there's some evidence that we don't have as much of a physician shortage in the US as we have a distribution issue where many of them just moved to the cities, and these rural health systems are shutting down. I imagine you magnify that by ten or a hundred times in many of these countries that Partners In Health works in, and so if you wouldn’t mind talking a bit more about UGHE. I know you were just there recently.

Dr. Sheila Davis: Yes, it's an amazing campus in rural Rwanda, and we work very closely with the Rwandan government, as well as many partners, and thank you for your support. We have a Master's in Global Health Delivery, and then we have a medical school and nursing leadership program, but the medical school enrolls about thirty to forty people each year -- we just started our fourth cohort -- and 75% of that group have to be women. I think that's to try to again, at least for the foreseeable future, we know we need to try to change the gender imbalance. Currently, it's been Rwandan students, as well as students from East Africa in the past few years, but next year, there will be students from our Africa sites of Malawi, Lesotho, Sierra Leone, and Liberia. So, we'll have Partners In Health motivating young, amazing people who will enter this six-and-a-half-year program of medical school, and the campus is really focused on community education. When I was there we went on a home visit with community health workers, and all of the medical students are embedded in the community and work in the community with community health workers. 

This amazing woman, a community health worker, when she was introducing herself, said, 'my name is Janine. I'm a community health worker, and I'm a university lecturer.' And I thought that is 100% what we were striving for. That woman -- who is truly the woman who is the person who is ensuring that pregnant women get to the facility to deliver, is able to make sure kids get immunizations, is really the foundation of that community -- is valued and sees herself as a university lecturer and sees that her responsibility is to ensure that those medical students understand the context and the lives and the shoes on which these women walk. It was one of the most amazing experiences I've had at Partners In Health. I immediately wanted to text Paul and say, 'Paul, you know, our vision has really come to fruition,' because he really saw the link between academic, clinical, and the community had to be a deliberate and authentic one.

Shiv Gaglani: Yeah, that is really powerful and hopefully, we'll hear more of those kinds of stories. Obviously, to scale the impact of training more healthcare workers, not just medical and nursing providers, but frontline healthcare workers, and community healthcare workers, we have a long way to go. What are some of the ideas Partners In Health, or just other organizations you've interacted with, have had that you think are compelling for us to address the massive shortage we're seeing globally?

Dr. Sheila Davis: I think community health workers was certainly part of the answer. We saw, as you said, that in the US, not having strong public health, a community-centered approach to health really showed during COVID the challenges with that. But I think we know globally, that certainly doctors and nurses are a huge need but also there are operational logistics. Logistics is huge. In terms of fighting the Ebola response, I had a very different appreciation and understanding of the need for logistics than I have ever had before because of trying to get PPE, of trying to get chlorine, and knowing that we couldn't do clinical care without that. So I think we look at the team needed to provide global health or provide health in general, is really, multi or interdisciplinary. 

We need to value drivers, we need to value chiefs of surgery, we need to value environmental health people and all of those people are critical. We need to push care into the community. Community health workers we see -- and there are 12,000 of them at Partners In Health -- we see as a core foundational piece of what we do because it's people from those communities, like that community health worker Janine, who are the foundation and hooks people into the facilities and ensures that people are getting care, those who need at most, but I think we need to broaden our view and look at ways of educating people in very different and unique ways. We're hoping that the University of Global Health Equity in Rwanda and eventually in Haiti will be a place where it can be a platform for educating many, many people not just the current programs we have.

Shiv Gaglani: Yes, that's an exciting kind of vision for that. Two quick follow-ups on that, I actually didn't know there was a UGHE planned in Haiti. Is there a timeline for that at this point?

Dr. Sheila Davis: One of Paul's biggest plans was to ensure that we had a university also in Haiti, and so it will take us a while. It will be a longer process. But we're building on the success of the residency programs that are happening already at the Mirebalais Hospital we have in the Central Plateau. We'll be starting programs in the next couple of years, and are really excited about taking lessons learned from Rwanda, but also really honoring the unique context of Haiti. All of our PH sites except for probably Kazakhstan and Russia were started by our Haitian colleagues who came from Zanmi Lasante or PH Haiti and moved to Rwanda and moved to Lesotho, moved to Malawi. So really, it is this amazing kind of network, and the heart and the activism, and that pragmatic solidarity really comes from Haiti. That's where we started and it’s an important piece of our history and our future. So really knowing that we want to have a university at some point in Haiti is also honoring that past.

Shiv Gaglani: That's awesome. That's great to hear, and obviously, if we can be helpful --like we have in Rwanda -- with those plans, we would be excited to be. A second follow-up is, you've got 12,000 community healthcare workers that Partners In Health employs. It's basically a large health system. How do you educate them and make sure that as things evolve -- COVID comes out, or new medications or treatments come out -- that they're up to date on their knowledge? Is there some service centralized thing? Or do you work with the governments? How does that happen?

Dr. Sheila Davis: I think all of the above. We work, obviously, with the governments because our care is embedded in the public sector. Our community health workers in Rwanda, for example, are all linked into the existing Rwandan Ministry of Health Community Health Workers system of which they also have many. I think we work on both with official things that happen with governments in terms of rolling out about COVID, for example, but also we have specialized community health workers, in mental health. We have specialized community health workers we do in NCDs (non-communicable disease). So we also provide that advanced training, and it's all done not in isolation of the community, but ensuring it's hooked back to our clinicians at our health centers, and hospitals, etc. 

We have community health teams in each place that we work, and that is hooked very much into our clinical care. Checking blood glucose levels at home, for example, which now community health workers do in Rwanda, is very much connected to our non-communicable disease clinicians at the health facilities in the hospitals so that we are ensuring that the right education is taking place, that also they're learning what is beyond their scope, and when they should be connecting and talking to nurses at the health center and in specialized positions. We considered health workers as such a core part of our work around the world. It's really embedded in our view of a comprehensive health system. So the ongoing education of community health workers is just as integral as the doctors and nurses and others that we work with.

Shiv Gaglani: That's awesome. That's really, really good to hear, and something we should definitely follow up on. We just started working with the Indian Government to train about 250,000 ASHA (accredited social health activist) workers, community health care workers, which should reach about ninety million Indian citizens or residents of India, and translation and cultural localization is a big part of that. You’ve preempted one of my questions, which is that Osmosis is a health education teaching company. If you could snap your fingers and train every healthcare professional or every patient out there on something -- on one or two concepts -- what would it be and why?

Dr. Sheila Davis: I think looking at health in a broad way…knowing that you have to address the social support aspects of it, I think is critical. I think we've learned through HIV work, which I obviously have done for so many decades, that you can provide the best antiretrovirals, but if you don't provide food, people are not going to do well. They're not going be able to tolerate the medications and they're not going to respond to the same way. I think if we are able to infuse that it's just as important that you're asking about a woman's life like at home – for instance, does she have food for her kids – that will stop the cycle of treating kids multiple times for malnutrition, because you're actually addressing the core issue of hunger and starvation. If we all took this broader view of comprehensive health and didn't see it as the ‘social worker does that’ or that's a "nice to have". We really need to see it as a core part of healthcare. If we were able to broaden people's view and see that housing, transportation, nutrition, opportunities for employment, etc, are key components of this -- particularly for the most vulnerable -- I think we would have much better outcomes, all of us.

Shiv Gaglani: Totally. I think that’s maybe one of the few silver linings I've seen from COVID is it has accelerated the adoption of everything from telehealth to value-based medicine. We're seeing a lot more of that, at least in the US. I don't know how much that's translated internationally. But certainly, these are key themes that are now part of a lot of medical and nursing school curricula.

Dr. Sheila Davis: I think that's so important because there are going to be different pathogens, there are going to be different pandemics, different viruses, but if we don't get this core piece of seeing people comprehensively, then we're going to continue to see pandemics and disease disproportionately impact marginalized people and vulnerable communities. So, that has to be built into our responses

Shiv Gaglani: I know we're coming up on time, so I have two more questions for you. You have a very unique background, both leading this 19,000-person strong global organization, but starting your career -- treating HIV and AIDS in the 1980s, and then also doing Ebola response -- you've now seen several pandemics come out of very different causes, very different responses, and lasting effects. Do you have any sort of overarching lessons you've learned or want to impart? Because obviously, there will be another one. It's inevitable. Any things you've learned that you'd love our audience to know about?

Dr. Sheila Davis: I wish we had learned more lessons from HIV to apply to Ebola, to apply to COVID, because I think we learned so much and we learned that stigmatization of diseases really does impact people's outcomes. I think even with COVID -- in terms of who was impacted, and who had the most morbidity and mortality -- we saw that they were from vulnerable communities, marginalized communities, which is the same as HIV. 

The answer, or part of the answer, is really having a strong community response. During Ebola, for example, we knew that having accompagnateurs, and community health workers are part of the answer. We knew that from HIV, we knew that from TB and MDR TB. So, we hired Ebola survivors in Sierra Leone, and they became our community health workers in educating about Ebola and how to keep safe, and that had a dual purpose. One, it also was this reach into the community, but it also valued those people, so they were getting paid, they were being respected, they were able to then have an entree back into their communities where they had been ostracized, similar to what happened with HIV, So I think knowing that any response to any pandemic or even anything that kind of impacts overall health has to include people who are embedded in the communities and there have to be localized solutions. We need to figure out how we're engaging communities, not as one-offs during an emergency, but most importantly beyond, so that there are strong relationships already made. 

In places where we had strong community health worker networks, we know that people were much more willing to take the vaccines because there was a trusted ambassador, somebody who they knew before, somebody was showing up to give them a shot. And so I think we have to learn from that and know that our best way of fighting any future pandemic is having a community-based healthcare tie and being part of a larger comprehensive system, but not having it be so focused in the hospital as it is in the US. For example during COVID, I felt like we were fighting for the same model, but in Sierra Leone, I was fighting for an ICU so that we could give an advanced level of care, and in Massachusetts and Montgomery, Alabama, we were fighting for community health workers to address social support. Part of the same model, but really looking at different ends of the spectrum, and still trying to provide the same model of an equity-based health system.

Shiv Gaglani: Well, I love those examples, and especially investing in the community sort of epitomizes that phrase "think global, act local."

Dr. Sheila Davis: Yes 

Shiv Gaglani: So, it sounds like you guys do a great job of that. We have an audience of two-and-a-half million registered learners, most of whom are current or future healthcare professionals and early-stage healthcare professionals across medicine, nursing, PA, and community health. What's your advice to them about meeting the challenges of this particular moment in time and approaching their careers in healthcare?

Dr. Sheila Davis: I think it's finding your foundational bedrock. For me, it was around activism and social justice, because of the HIV community and vulnerable communities, and how they were impacted by something like HIV. I think it's finding the thing that you're passionate about, but also be willing and open to learn from different communities. I learned a tremendous amount from the HIV activism community and it really impacted my entire career. If I hadn't been open to people who look different from me, who came from different backgrounds, who had totally different life experiences, I don't know where I would be now. 

I think it's really being open to that, and valuing the expertise of the lived experience. Recognizing that your teachers may be that community health worker, Janine, who can't read or write, or it could be somebody who's, you know, an expert neurologist at a top teaching hospital. Both are very, very valuable. I think learners and students being open to that, I think, will put people on the right path.

Shiv Gaglani: I love that, and it kind of validates, again, that thing you learned in medical or nursing school of your patient being your best teacher, ultimately, and just viewing everyone as a source of learning. Well, Sheila, thank you so much for taking the time to be with us today and most importantly, for the work that you've done over the past several decades to advance health equity and improve health outcomes globally.

Dr. Sheila Davis: Thank you. And thanks so much for your partnership. We know it's really important that we take these important resources and make them available around the world. And so we really appreciate that.

Shiv Gaglani: Totally, your team is fantastic. We love working with UGHE. So with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show and remember to do your part to flatten the curve and Raise the Line. We're all in this together take care.

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