Shaping Ethical Global Health Education with Ashti Doobay-Persaud, MD

• Doobay-Persaud’s global health story started early at age 11, when she first encountered Médecins Sans Frontières, or Doctors Without Borders, at the French school she attended. From that moment, she knew she wanted to be a doctor who traveled around the world to support others.
• Doobay-Persaud worked with the NGO Himalayan Health Exchange to provide short-term medical care in rural camps and for an antiretroviral therapy clinic (ARV) to treat and prevent HIV in South Africa as a Yale Johnson and Johnson scholar. She started learning more about ethical practice and thinking critically about the harms of short-term global health work. 
• In Borneo, Doobay-Persaud was responsible for managing the students and residents from high-income countries and steering them toward ethical and sustainable practices. It was this experience that turned her attention to a major gap in global health training: supervising faculty and preceptors.
• Doobay-Persaud shares guidelines for trainees working in an unfamiliar location and culture. She emphasizes cultural humility and working within your scope.
• Doobay-Persaud founded the Northwestern Master’s in Global Health program with Rob Murphy, MD, in 2016. To make high-quality global health education accessible to low and middle-income countries, the program is virtual and asynchronous. 
• COVID-19 shifted the approach to global health and global health education, Doobay-Persaud says, for the better. The necessary pivot to all-virtual communication at the height of the pandemic has resulted in more frequent communication with global partners. This reliance on global partners during the pandemic also shifted the power dynamic, making projects more localized.
• As a clinician and educator, Doobay-Persaud initially didn’t prioritize publishing and research. She now encourages students and others in global health education to pursue publication. Research and scholarship helped build the field of global health education.

[00:00:00] Dr. Rob Murphy: Welcome to the Explore Global Health podcast. I'm Dr. Rob Murphy, executive director of the Havey Institute for Global Health here at Northwestern University Feinberg School of Medicine. Today we're joined by an international leader in global health education who also happens to be my Northwestern colleague, Dr. Ashti Doobay-Persaud. She's an expert in ethical practice and competency-based curriculum development in global health education and is collaborating with partners around the world to support locally driven teaching, including training in palliative care, simulation-based education and faculty development. She serves as director of the section of global health in the Division of Hospital Medicine at Northwestern Medicine, and she is the co-director of the Center for Global Health Education at the Robert J. Havey, MD Institute for Global Health, and she's an associate professor at Northwestern University Feinberg School of Medicine, among other roles which we'll talk about today. She's also recognized by the Consortium of Universities for Global Health with the Hall-Sewankambo Mid-Career Leadership Award. Ashti, welcome to the show. Thanks so much, Rob. And thanks for having me on the podcast.

[00:01:20] Dr. Ashti Doobay-Persaud: You earned your MD from Tufts University School of Medicine. What first inspired you to study medicine and global health. My story is a little bit cliched. When I was 11-years-old, I went to a presentation at the library. I went to French school. And at the library, there were a number of doctors there from a place called Médecins Sans Frontières, or Doctors Without Borders. And they told a story of being able to be a physician and go to all of these international places where aid was needed and support was needed. And that was their job. And I remember coming home and telling my family, do you know that there's a job that you can get paid, that you can be a doctor and go around the world and support people? This is my dream. This is exactly what I want to do. And so, essentially my entire career or, sort of, my life goals started when I was 11, wanting to be someone with MSF or a doctor without borders. And I guess that's the genesis of my global health story. 

[00:02:23] Dr. Rob Murphy: It's fascinating thatMédecins Sans Frontières was an instigating factor in your decision to get into global health.

[00:02:29] Dr. Ashti Doobay-Persaud: And not just me, right? I think on the world stage,Doctors Without Borders is well known. That's exactly how I got inspired.

[00:02:37] Dr. Rob Murphy: And it remains on the world stage.

[00:02:38] Dr. Ashti Doobay-Persaud: Mmmhmm

So during medical school, and through your internal medicine residency at Yale New Haven Hospital, you provided clinical care and partnered with the NGO Himalayan Health Exchange. You also worked in an ARV, antiretroviral therapy clinic, to treat and prevent HIV in South Africa as a Yale Johnson and Johnson scholar. Tell me more about those experiences and how they affected your understanding of the relationship between healthcare and communities. So when I was a medical student at Tufts, there was, like, a pamphlet on the board of the office of medical education that said, " Come to the Himalayas!" So I took this pamphlet, and I took out a loan, and then I subsequently went to the Himalayas to provide short-term medical care in rural camps. And I had a really great time. I got to meet a lot of people. I got to go to the Himalayas. I got to feel like I was providing care. But as I was sort of working in that area, it became clear that there were some sustainability issues and there were some issues around short-term care or Band-Aid care, going and providing care to people without having many skills. And so I said, I think that I might need to learn a little bit more about how to do this well. And I need somewhere where this work is done in an ethical way and in an organized way. And so, my next step in choosing my residency program, I chose the only two residency programs in the country that had any international health rotations. That's how I did my residency rankings. It was that important. And at the time, Yale had the Yale, Johnson and Johnson International Fellowship. So I went into residency knowing that I needed to learn a lot about global health and how to do it well. But that I still wanted to do the work. So I was lucky enough to be part of the 2008 -2009 rollout of ARVs. And I was in KwaZulu-Natal in South Africa, and I worked in this really beautiful antiretroviral clinic in a place where there were pretty limited resources and a lot of need. And you know, I did the hard work that felt really like you're taking care of patients and there are long lines and you work all day and you provide care. And it felt gratifying and like I was doing that direct service. But still, I didn't really know much about who the major players were in global health. I didn't have much pre-departure training. I didn't really know about the ethical nuances. I didn't really know much about the community health workers or, like, the community-based palliative care that we were seeing there. So slowly started to learn, you know, about structures and systems and ethical practice and humility you know, really leaning into what are the local physicians trying to teach or how can we support local physicians, those different nuances started cropping up. And at the end of that eight-week rotation, I knew that I wanted to learn a lot more to do everything much better than I was doing it. And so I ended that learning about sustainability, learning about local practice while I was there and learning about ethics and knowing that at the end of that, I wish everyone else knew that. I wish when I was a medical student I knew that I wish all my other residents knew that. And I sort of wish every resident knew that. And all these young, talented people who have a lot to give need to know how to do this work well and to avoid a lot of the harms that come out of doing short-term global health work.

[00:06:19] Dr. Rob Murphy: I don't think you were alone in 2008 with that situation because global health really began evolving right around that time. It was basically well meaning people from high income countries, like you and me and many others, and it was the beginning of this whole transformation into global health. But I appreciate your comments on you learning about the need for these systems and the sustainability component.

[00:06:50] Dr. Ashti Doobay-Persaud: You make all the mistakes, right? Like that's that's how you learn it, right? So, yeah, exactly. I think you put it perfectly. It's like, all these people with such good intentions and then all these unintended consequences and harm. I think that's the beginning of the global health story and the middle of the global health story and still a little bit, but I think we've made a lot of progress over time.

[00:07:14] Dr. Rob Murphy:After you completed your residency, you were a physician volunteer at the ASRI clinic in Borneo. Can you tell us what that is, and why did you decide to do volunteer work at that point of your career, after finishing your residency?

[00:07:29] Dr. Ashti Doobay-Persaud: Sure. I think I've always volunteered, throughout my career, in some way. I actually thought of that as my first global health job, that volunteer stint at ASRI Clinic. It's a clinic in Borneo that was started by a former Yale resident, Kinari Webb. She founded the NGO called Health in Harmony that marries environmental health with human health, like all the way in the 2000s she started that. And she saw it was critical to have environmental health, particularly in the rainforest. And this clinic was very sustainable. The way that they used high income country doctors was our job as faculty was to train Indonesian residents. So I had a job already. I had gotten my job at Northwestern as a hospital medicine doctor and had asked my boss, Do you if I start in four months because I'm going to be volunteering in the Himalayas and then volunteering in Indonesia to do some work and I wanted to volunteer in a clinic somewhere where people were doing primary care skills and where I could teach. And so I had a chance to support and teach Indonesian residents at that clinic. And during my time there, I learned a lot about sustainability, just on the ground. And I actually organically grew my global health knowledge at that time. There was an organization, Unite for Sight, that's been around for a really long time. And in 2009, when I went to volunteer at Borneo, I knew that I needed to learn about global health because I was like, I keep doing this thing, but there's not really knowledge and skills around this. So I actually, like, went online and learned, went through all the modules from the Unite for Sight Global Health University while I was working in Borneo and sort of learned what the tenets of sustainability were and local practice and then implemented them in the clinic. And a lot of what I actually had to do, in addition to sort of managing patients and the residents, was to manage the high income country students that were there and residents and to steer them into doing ethical work and actually guide them into local sustainable practice. Half of my job was managing our high income country residents who wanted to do the knee-jerk. I'll pay for the CT scan for the patient if they can't afford it, I'll pay for medications or disrupt systems So it was my job to kind of keep the systems going. Oh, and I learned a lot about how to partner with locals and how to elevate local healthcare workers in the clinical space, which is a lot of what this clinic was dedicated to doing. And then actually working in the Himalayas, those two situations made it very clear to me that it was easy for students and residents to go work abroad. They could find funding and time, but the clinics really needed faculty and needed preceptors. And that was the big gap. So that's why I ended up going to ASRI for two months. There were no preceptors. So supervising faculty were a struggle for so many of these NGOs that I was working with. So I kind of, early on, was like, Well, this is a need I can fill. It's pretty straightforward. And so that's why I started doing that to fill that gap.

[00:10:54] Dr. Rob Murphy: So your training and immediate post training days really took you to Nepal, South Africa, Borneo. Let's talk a little bit more about Northwestern. You lead the Northwestern Center for Global Health Education, and you founded the McGaw Global Health Clinical Scholars Program for graduate medical trainees at Northwestern. What drew you into training and education here locally?

[00:11:22] Dr. Ashti Doobay-Persaud: I remember at my residency graduation my program director was asking me, you know, What do you think you're gonna do? What's next for you? And I said, I just came back from South Africa and I learned so much about how to do this work the right way, and I think there's like a big opportunity here to teach people how to do this well and not regret things they've done for a decade or all the money they spent, right? I would love to teach young people how to do this right the first time. And so actually what my program director said was like, Oh, so it sounds like you want to do infectious diseases. And I said, No, no, no, I don't want to do infectious diseases. And he said, Oh, so it sounds like you want to do an MPH. And I said, no, I don't want to do an MPH. Like, I want to do something that teaches people how to do work in the global health field in ways that are, you know, supportive and ethical and point towards equity. And he said, Are you sure you don't want to do epidemiology intelligence services? And I said, no, I really don't. And I said, you know, I think I'll figure it out over time. But really, it's kind of what I wanted to do the moment that I learned that there were principles and practices and ways to do this well. I was like, oh, I got to tell everybody before they get started. So they start on the right foot.

[00:12:45] Dr. Rob Murphy: I know when we started the Center for Global Health, which ultimately became the Havey Institute for Global Health, we were very happy that you developed these programs, so well to train people. The result has been quite palpable

[00:12:59] Dr. Ashti Doobay-Persaud: I spend a lot of my time really thinking about what a trainee can do to mitigate or do the best job that they can. And so some of those things are: the first is really exercising cultural humility. I think that's probably the foundation. What I mean by that is our trainees acknowledge that they're in an unfamiliar setting, in an unfamiliar location with unfamiliar ways to think about health and disease and, even in a very unfamiliar culture, how to manage and interact with people. And trainees at the very core should be positioning themselves as trainees or as learners, right? What I ask them is: to ask, to be humble, to look for guidance from local partners and really to act as learners. So that's really step one. Maybe the second thing I have is some aphorisms. Don't do anything there that you wouldn't do here in quotation marks. I sort of say things like that, but I really mean like, do not practice outside of your scope of training. Do not do any harm. When you're doing this work, you must be holding the highest standard of clinical excellence at all times. You're an ambassador for the profession and you're an ambassador for the school. This ethical practice and really understanding how to practice within your scope, but also how can you navigate ethical challenges to support some kind of positive outcome is something we teach them that's a little bit nuanced, and we really drill down into it. We try to teach residents skills to identify local resources to manage ethical problems. They have these whole simulation days where they're presented with really challenging cases. And the answer is never that the resident does something outside of their scope. The answer is always that the resident figures out who around them can support figuring this out and how they do it without breaking enormous cultural norms and partnership norms. And I think do no harm, but the devil is in the details. The question is, will the residents know what can be harmful? So, we really try to spend time thinking about what does harm look like? And then this last point, it may seem very granular, but if there are any residents or trainees listening to this, I kind of want you to hear this. It's this idea that there's time to figure stuff out. People get really nervous about emergencies or moments where they're asked to practice or do something that's outside of their scope, but always take time to see what's urgent, what's emergent. What do you really have time to do? There's always time to find someone who knows more about what to do than you do. I mean, and if it's an emergency, it's an emergency and the chips fall where they may, but most of the time it's like semi-urgent or there are hours. Like every time I get called to deliver a baby, I always spend the hours finding the midwife. You know, like those kinds of principles. And I think maybe the other thing for the trainees, is thinking about, like,the hubris of the American trainee too. So, for example, you see someone who needs to be ventilated and you use the only ventilator and then a young person comes in who needs dialysis, you know, like just the sort of distribution of resources, we just don't know them, right? Like you have to ask the head of the hospital, the head of the clinic, what the right thing is to do, given the resources and the time.

[00:16:44] Dr. Rob Murphy: You're the faculty director for Northwestern's Master of Science in Global Health program. Global health is such a vast field, and besides traditional paths in medicine, what are some of the other career paths students follow after this master's training?

[00:16:58] Dr. Ashti Doobay-Persaud: Yes, this Master of Science in Global Health that we founded, 2016, Rob, who you founded...

[00:17:07] Dr. Rob Murphy: Right, so you and I founded it!

[00:17:09] Dr. Ashti Doobay-Persaud: That we founded, literally, you and I founded. We really created it to sort of fill two gaps. I want to acknowledge the first gap, which was your mission, which was that colleagues of ours from low and middle income countries who couldn't travel would still be able to access high quality global health education, right? So that was one of the main reasons we formed the masters, because the masters is completely online and asynchronous. So, one of the reasons we did it was for our colleagues who are becoming young researchers to have access to Northwestern teaching and instruction. The second part or the second reason, and it'll come through what students do, thinking about who the students are when they come in. So the students that our MSGH serves are typically students who are professionals already or are ready to pivot their careers, and the ones who want to pivot their careers can come from different fields, or the third arm is really those who are in the health professions field already, they're kind of mid-career and they're ready to commit to global health in some way. And so we created a program to teach professionals, mid-career individuals, how to engage in the global health space, what the foundational principles are, and what are the most important skills that you need to engage. So partnership skills, communication skills, grant writing skills. So those are all skills, but kind of like what I said in the beginning, you know, when I was a first-year medical student, second-year medical student doing global health, people also need to know the entire global health system and space. So who are the major players? What are global health systems? What is the number one killer of children under 5? They sound disparate, but they are all knitted together in being foundations of global health. And so, we really want to teach folks these principles, these skills, so that they can go ahead and launch into a global health career space with that knowledge. What does that look like for their careers? So you'll see a lot of, maybe a third of, folks are clinical and so they're adding global health onto their clinical career in some way. And we really need to reach those folks so we can teach them some of the clinical best practices, do no harm, do's and don'ts. Then this other third who are, like, really interesting, right there. Administrators, judges, lawyers, people who run foundations or who are the heads of foundation NGOs or stateside NGOs, or even like in-country NGOs, people who run government grants or government programs in global health, that's the sort of middle third. And so those are the people that are already working in global health, but want to shore up their skills or they are ready to pivot. There's like a new position in their company that's global, and they're ready to do that. And then the third group are the young students, right? Those who just graduated college, who are trying to figure out what to do next, who have more options than just, you know, an MPH or fellowships, now they have an MSGH because that's exactly right what I was looking for when I was finishing residency. I would have loved to have an MSGH. I would have fallen into that first group of clinical folks who are looking to do this work.

[00:20:36] Dr. Rob Murphy: Can you just give a couple, without naming any names, of course, a couple examples of what happened with some of our graduates in this program?

[00:20:44] Dr. Ashti Doobay-Persaud: A group of them have started to work in global pharmaceutical work. We have one physician who became the head of a community health worker program in Mozambique. Two or three, if not more, of our graduates work for different departments of public health. And then we have a couple of our graduates are directing LMIC-based NGOs on the stateside level, so they got the NGO director stateside job for a foundation in Uganda, for a foundation in X or Y where they're looking for U.S. partners. And then we actually have a graduate that works right here, at the Institute for Global Health, supporting our malaria programming and our work in that space. And then, you know, there's the young ones, that third group, many of them go on to medical school. It's pretty common. And that's great because they're learning all that global health stuff before they go to medical school, before they get the skills to understand medicine and healthcare delivery.

[00:21:46] Dr. Rob Murphy: That's great. It's really fun to look at that program and see how it's evolved. Let's talk a little bit about COVID. COVID-19 has had an impact on the way we learn and work, and at the height of the pandemic, you actually published a paper on the effect on global health education specifically. Can you give us some of the takeaways of that and what we've learned in these last few years that could make global health education more effective in the future ?

 Yeah, the pandemic really gave us a chance to sort of pause, I think, and reassess global health education and think about ways that we could do it differently. It became really clear that our students, particularly our master of science and global health students, when they engage with partners virtually, a lot of the work they do is actually the work of an academic, so reviewing policy, reviewing literature, analyzing data. All those things can be done at a desk at home and can greatly support partners' work. And so we redesigned a lot of our programs to be virtual and we redesigned our partnerships to be virtual. And it turned out that a lot of those fungible resources that weren't being used were saved, right? We could do a lot more with our partners, no plane tickets, food costs, et cetera, and we could still build and learn and contribute. And so we realized that it was time to start thinking about changing the paradigm and perhaps thinking about spending time with partners rather than travel. So I think the timing really worked out for us too, because we spent two years virtually with partners doing education. And when we hit the limit of what you can do virtually, we were allowed to travel again. But we had spent all this time building relationships and contributing.  Yeah, I agree with you completely that the paradigm has dramatically changed, and I think it's for the better. It really forced us to shift a lot of the responsibility and training and leadership to our partners in low and middle income countries.

[00:24:03] Dr. Ashti Doobay-Persaud: We actually gave a talk on this at CUGH (Consortium of Universities for Global Health), but how the virtual partnership has shifted the power dynamic. This idea of, like, all the leadership should be local. All the activities should be local. The funding needs to be more localized. Everything needs to be really centered around our partners in a way that I think we always imagined, but were forced to do it. And now there's no looking back. This should be the standard, you know, and I think that it kind of really moved us into a place where we can talk the walk of equity and bidirectionality and shared power, or the best version of that, that we can do.

[00:24:47] Dr. Rob Murphy: It's a different field, and I think it's much better. I understand that you're the academic editor for PLOS Global Public Health, a journal, and a guest editor for Pedagogy in Health Promotion. How'd you get involved on the editorial side of journal publishing? Even start with, when did you publish your first paper?

[00:25:06] Dr. Ashti Doobay-Persaud: So I showed up at Rob's office with my CV in 2009. I was a clinician and I was a teacher and that's sort of what I had envisioned. It turns out I'm at a very robust academic medical center and part of the work there is really being an academician, or an academic. And, Rob looked at my CV and he said, Boy, you've done a lot of work, which is great. I'm so happy to see this. I don't see any papers on here. You need to start thinking about contributing to the literature, establishing the work you're doing and actually studying it in a systematic manner. So I started to say, Okay, well, you know, I'm not doing clinical research. But I'm building all these academic programs, and so I guess I should figure out what is impactful, what are the things we're doing well, what are our learners learning, and what should our learners learn? So maybe I'll start there, and I'll also maybe start looking at the health services space, because those are the two spaces I live in as a clinician and an educator. And actually, the first paper I ever published was because one of my medical students said I really need to do a scholarly project. I must do it in global health because it's so important to me. Will you please help me figure out what to do? So I said, sure. And we worked on, you know, a quality improvement needs assessment for the clinic in Belize, the first clinic that I started working in as a hospitalist And then I started to write about our master's program. I started to think about, if our students are not embedding themselves in sort of long-term research projects, what does scholarship look like in that case? And it looks like educational scholarship or community based scholarship. And so we wrote a paper on what are scholarly projects in global health for the short-term practitioner? How can you turn your work into scholarship? And it was really like getting to do all the educational work, all the equity-based work and turning it into scholarly work and disseminating what we learned. And so, that's when I started to write a lot of articles about how we should be teaching global health, what our best practice is. And actually, the first big research project I did was to answer that question. Like everyone talks anecdotally about, you know, I got to remove an appendix or I delivered all these babies, all those harmful practices. People always told those stories with a little bit of like gory glory kind of thing. And I actually set about to codify those stories into actual numbers. I actually surveyed, like 223 experienced global health practitioners, like people who'd been working in the field for five or 10 years and asked them, what were their stories? What was the lasting impact of practicing outside of their scope? You can look up that paper. The numbers are very sobering. Nearly half of the people are asked to practice, nearly a third do, nearly 30 percent have persistent moral distress because of the outcomes. I'd heard so many of those stories, I kind of really wanted to know what the truth was. So that's where it became clear that research, scholarship and looking at things systematically was important to building our field. And now we have a field. Right now, I was asked to be a guest editor for a Frontiers edition on global health education. I'm almost finished writing my editorial, but we were able to really push that journal to create a space for all the people who are doing work in global health education. It's about research and critical discourse in global health education. So we talk about decolonization. We talk about capacity building. I think I can say comfortably that global health education is a field of practice and scholarship now and we really worked hard to make that a reality.

[00:29:15] Dr. Rob Murphy: It's been so much fun to see the development, your development and the development in the field. I have one final question I ask everybody I interview, all my guests. What advice do you have for young people who are now just embarking on a career in global health?

[00:29:31] Dr. Ashti Doobay-Persaud: I would say, follow your passion, do the hard work and take the opportunities as they come. We get a lot of serendipitous opportunities. And just make the best of those. I was asked to do so many different things you've heard about on this podcast as sort of like an offhand ask. And just saying yes has gotten me really, really far. You do it for equity, you do it for justice, you know? So if you keep those principles in mind, I think you'll do great things.

[00:30:05] Dr. Rob Murphy:  Ashti Doobay-Persaud, thank you very much for joining us today

[00:30:09] Dr. Ashti Doobay-Persaud: Thank you.

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