Diversifying the Field of Global Surgery with Juliet Lumati, MD, MPH

• Lumati grew up with a single mother and two siblings in a poor area of Lagos, Nigeria. Her mother won a lottery, literally, for an American visa and they immigrated to Chicago when Lumati was a child.
• Lumati was drawn to biology and political science from a young age, but medical school didn’t seem like a viable path after working multiple jobs to get through her undergraduate degree at the University of Georgia. A lifelong volunteer, she was also always drawn to helping people and giving back to communities like the one where she grew up.
• A potential career path in global health became clear to her after studying political systems in Tanzania. There, she saw herself in a “global context” as a person trained in the U.S. returning to her home country. 
• Before applying to medical school, Lumati worked in health policy through the Barbara Jordan Health Policy Scholars Program on Capitol Hill. This experience illuminated how she could merge an interest in clinical medicine with healthcare policy, which led her to pursue a health equity track at the University of California San Diego School of Medicine and an MPH from Harvard T.H. Chan School of Public Health. 
• There were few models of black female surgeons in public or global health, Lumati recalls of her medical training. She thought she would need to follow a career path in infectious diseases, but she really wanted to be a surgeon. She realized global surgery was the right path for her after working at the Harvard Center for Surgery and Public Health.
• Through a one-year University of California Fogarty-NIH research fellowship, Lumati expanded her interest in healthcare financing to a global scale. In her study, she found that the national insurance plan in Ghana was not adequately addressing the financial burden on patients. Northwestern University offers a similar fellowship, the HBNU Fogarty Global Health Training Program. 
• Now an assistant professor of Surgery at Northwestern, Lumati works in Chicago and, abroad, at the Lakeshore Cancer Center in Lagos. She consults remotely on a tumor board and also has protected time to travel to Nigeria for patient care. Additionally, she is investigating interventions to ensure patients finish cancer treatment and get funds for their cancer care.
• Studies and practices in high-income countries often inform cancer treatment guidelines in lower-middle-income countries. To address this gap in care, Lumati is investigating a clinical trial portfolio that reevaluates the standard chemotherapy regimen in a resource-limited setting.
• To improve the diversity of clinical trials at Northwestern, Lumati is exploring financial navigation programs, bringing trials into under-resourced communities, and diversifying the teams who are leading trials.
• While pipeline programs have increased the number of surgeons from underrepresented groups in medicine, Lumati believes that greater retention efforts and support will be the key for these surgeons to succeed in the long term.

[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, I'm pleased to be joined by Dr. Juliet Lumati, a global cancer surgeon whose career has taken her from her home country of Nigeria to the States and back again. Through her research and clinical practice, she aims to bridge the gap between clinical medicine and healthcare policy in low- and middle-income countries. Dr. Lumati is now an assistant professor of Surgical Oncology at Northwestern University Feinberg School of Medicine, but she continues to work abroad, mainly in sub-Saharan Africa, where she is working to improve access to cancer care. Thank you, Dr. Lumati, and welcome to the show. We really appreciate you joining us today.

[00:00:59] Dr. Juliet Lumati:  Thanks so much, Rob. It's so good to be here. Let's start at the beginning. 

[00:01:01] Dr. Rob Murphy: Let's start at the beginning.  Tell me a little bit about your upbringing and your journey to Chicago as a child. I understand you were born in Lagos, Nigeria, a city I've been to many times.

[00:01:13] Dr. Juliet Lumati: Yes, yes, yes. I was born and raised in Lagos, Nigeria in an area called Surulere, which is sort of the urban slums of Lagos. My mom was a single mom with three kids, really trying to hustle through Surulere to make ends meet. We were fortunate where she was sort of working at a bank as a secretary and was approached by someone on the street to play a U.S. visa lottery to win a trip to America. And she ignored this person for several days and finally she said, Okay, fine, let me play this lottery. And it turns out that we actually won this lottery ticket to come to America, and she immigrated to the United States with all three of us. And so we landed in Chicago in O'Hare Airport, which was a really life-changing experience for us. And it's so exciting to come 360 around and to come back where I actually started with my practice here.

[00:02:07] Dr. Rob Murphy: That's an amazing entry into the United States, I must say. Well, congratulations to you all. I understand your sister is also a physician. 

[00:02:16] Dr. Juliet Lumati: That is correct. My sister is an emergency medicine physician. She's also had some interest in global health. And in fact, has spent some time working at Korle-Bu Teaching Hospital in Ghana. And I think we all sort of share this palpable passion to really give back to communities that were very similar to the ones that we grew up. And that's really the driving force, I would say, in my family.

[00:02:38] Dr. Rob Murphy: While you were studying at the University of Georgia for your undergraduate degree, what did you think back then about what you wanted to do for your career?

[00:02:46] Dr. Juliet Lumati: I was very undecided for a very long time. When I think about kids these days, they're like, I want to be an astronaut. I was like, I don't even know what that even meant. I just couldn't even see past Surulere, right? I saw the stars and I thought they looked very bright, but that was the only thing I was super excited about. Before, when I enrolled at UGA, I knew I always loved biology, but I also loved policy and political science. And so when I went to high school, I actually studied both. I hated chemistry and physics. When I came to undergrad, I kind of had an idea that I wanted to study biology, but I wasn't sure what that was going to look like. I knew I was passionate about giving back. I worked with Habitat for Humanity. I worked for the International Red Cross. I was raising funds for March of Dimes, and I really just loved volunteering. It seemed so natural to me. And when it got to sort of my third year of undergrad, I started to volunteer at a regional medical center. And that was when it sort of hit me that maybe this is what I'm actually really meant to do. I just love this so much. And I love helping people. But then the journey to go to med school seemed so arduous, given the fact that I had to work two, three jobs to even try to support myself through school. And it was very, very difficult even just getting through college that I just could not imagine what it would be like to be a doctor. I didn't have a family member that was a doctor. I didn't know if it would even be something to consider. And then at some point in time, I turned my domestic passion for helping people to study abroad. And so my first study abroad trip was in Tanzania, and I really loved that trip because finally I started to see myself back in the global context and really figure out what it actually meant to be a U.S.-trained person coming back to study about political systems in Africa, which was the course I was taking there for two months. And it was actually on that trip, I started to interact with people, you know, physicians with Doctors Without Borders and several organizations that I started to see, huh, maybe I can be a doctor without a border. Maybe I can see myself really bringing this to communities. And so when I came back to the United States after that trip and my experience at the regional medical center, that all sort of fulfilled me and made me decide that maybe I should figure out a way that I can make an impact through medicine. And luckily for me, I had the mentor that actually sponsored me, Dr. Dunning, to this trip in Tanzania was very excited about this idea and has actually continued to be a longstanding mentor of mine. So that was sort of how that came about. It was sort of a combination of my experiences volunteering for different organizations, particularly also being in the hospital system, coupled with some early experiences going back to the continent and trying to merge an interest in helping people with a potential career in global health.

[00:05:36] Dr. Rob Murphy: Let's follow up with that political side a little bit. After college, you worked for Senator Tom Harkin. How did this experience shift your career path towards medicine and global health?

[00:05:48] Dr. Juliet Lumati: Yeah, you know, it's interesting. I was looking for a job. Um, so I decided that I was going to finally brave it up and apply to medical school. Before that, I said, maybe I should do the Peace Corps first. So I actually signed up for the Peace Corps. I was actually going to go to Cameroon and teach for two and a half years. I was ready to pack my bags and then something just really hit me. And I was like, well, you really want to do medicine and you want to do global health. Why do you keep running away from this? Why do you just keep looking for ways to get around this? Like you can make an impact in Cameroon. Well, gosh, could you make even a bigger impact having a medicine background? And so that was sort of what had me rethink how I was going to approach this idea of going to medical school, and I decided to take some time off so that I could work and save up money to study for the MCAT and apply to medical school. Turns out that I was applying for opportunities and internships, and I found this internship called the Barbara Jordan Health Policy Scholars Program, which brought recent college graduates to Congress to work as congressional staffers to put us in different senators' offices as well as staff to really learn about what it meant to actually make policies on the Capitol. And luckily for me, I was assigned to Senator Tom Harkin because of his role as a ranking committee member in the Health, Education, Labors and Pensions committee. And this was actually during the drafting of the Affordable Care Act. And so my role with the office was to do research on the role of Medicaid and Medicare. I'm particularly looking at the audit for the uninsured. I wrote policy memos. I did debriefings with different staff. My favorite experience was actually being on C-SPAN and how straight I had to keep my face to be on C-SPAN as a congressional staffer. And I think this was the experience that really solidified my career path. From there, I actually started to recognize the disconnect between people that actually made policies with the actual people that made patient care. The people that actually saw the faces of Medicaid were not the same people making policies. And I realized that I wanted to be a physician where I could bridge that gap, advocate for my patients on a global level and really still be connected to them where I can understand the true needs that they actually had. So I was, then, really inspired to merge an interest in clinical medicine and healthcare policy. And that was what brought me to the UCSD program in health education, health equity track, which would actually now prepare me with an additional master's program in public health and health policy and management and with my clinical medicine interest and experience. 

[00:08:21] Dr. Juliet Lumati: And so I think, having these Programs like the PRIME program or health equity tracks allow you to understand what it's like to do policy, what it's like to do cost-effectiveness analysis, what it's like to do advocacy, what it's like to do data science and implementation. Those are the areas I found myself really much more excited about because now we have the evidence to support why we should be changing this narrative for a whole population of people.

[00:08:47] Dr. Rob Murphy: So you trained at the University of California, San Diego, UCSD. And then you got the, like you mentioned, you got the MPH in health policy and management from Harvard. How does your research and academic background now inform your work as a clinician, and vice versa?

[00:09:06] Dr. Juliet Lumati: I think it's so intertwined. I think my personal experiences growing up in the urban slums, no running water, sometimes no light, dealing with poverty, and I think that all of that perspective informs the kind of studies that I do. So I consider myself a health services researcher within the context of global oncology. What I'm passionate about is not necessarily if I discover a new drug for cancer; it's discovering better ways that more people can have access to that drug. So I feel like as a clinician, I was always that person, even on the rotation and wards when people were like, I don't understand why this patient is not following up. I'm like, because they don't have transportation, or they have four kids and they can't afford a meal. Did you see that they were actually asking for vouchers as family members to eat in the cafeteria because they're here with their family and they can't even afford to eat, right? And these are things that were just intuitive to me when I walked into the room, I could already tell the people that had and the people that hadn't, even before social work and really trying to, like, understand that in order to keep this patient in care or to make sure that this patient has the support that they need, we need to go beyond medicine from a doctor-patient perspective. And we need to think about circumstances and systems. For me, It has really changed my practice. So for example, I always make sure my patients have appointments before they actually get discharged from the hospital. I screen patients for transportation barriers before they leave. We ask them, Do you have problems with food or do you have difficulties planning your tasks? These are things that people are doing all this research about patient-reported outcomes and, you know, it's an academic thing, but for me, it was a true thing. Every time you had to go to the hospital or, in Nigeria, had to go to a provider, you got into a bus, you may have to take two or three buses to get there. And there are barriers to people that have to keep a regular job. And I feel like I look at a patient in a holistic environment. And I feel like I'm always forced to think beyond being a surgeon. And I think that that perspective has really changed the way in which I practice medicine. It also has changed my academic pursuit in terms of the type of research that I actually focus my time on researching.

[00:11:17] Dr. Rob Murphy: Let's talk about your surgical training. You completed your surgical residency at UCSF and the University of Alabama, Birmingham. Then you did a surgical oncology fellowship at Johns Hopkins. As someone with an interest in global health and policy, how did you get into surgery?

[00:11:36] Dr. Juliet Lumati: For a very long time, I thought I wanted to become an infectious disease doctor. I mean, you get the sense that, like, you don't really grow up with a lot of mentorship. You just do what you think people say you should be doing, right? You never have a chance to really think about being a surgeon, I just thought the best way to get into doing global health was dealing with the burden of infectious diseases. And so I had spent time between my first two years of medical school, I did a research project in South Africa. I came in, I was working at Owens Clinic at UCSD in San Diego with Dr. Sitapati, who was sort of really a fantastic mentor up until now. I mean, UCSD has a very big HIV population and I really got an opportunity to work with that population. I was working in our free clinics And when I got to my third year of medical school and did my rotations, I loved internal medicine. I got honors in neurology. And I got to surgery. I really loved the operating room. I was on trauma and transplant, both very different, and I really started to see health disparities in different ways. A lot of patients that came in through the trauma bay looked like me. And now I'm the provider, and that's the patient. I start to think about what were the circumstances, disparities that existed where we look alike. I, and yes, I had my struggles in Nigeria, but gosh, this is very bad. Gun violence, drug problems in many of these communities. And so I started to see maybe I can actually do this and really merge these career paths in public health. And when I got to transplant, going on those procurements and seeing a patient that was in the ICU, could barely open their eyes to talk to you to now being able to walk out after a transplant and the technicality of the operations, I just knew I wanted to be a surgeon. But then I was like, Are these surgeons my people? Because I didn't feel like I had great examples of surgeons that were doing things in public health, and so I began to explore that. I was like, Okay, maybe I'll do anesthesia. I did an anesthesia sub-I [sub-internship], and I was looking at radiology. I did so many sub-Is to convince myself that I didn't want to become a surgeon. And right at that time, that was when I went off to Boston to the Center for Surgery and Public Health and worked with Robert Riviello, and it just hit me that I found my tribe.

[00:13:48] Dr. Rob Murphy: Yeah, he's a great mentor. As a GloCal Fogarty NIH Research Fellow in 2017 and 18, you investigated a national insurance plan in Ghana. Tell me more about those findings and your interest in healthcare financing in global health.

[00:14:04] Dr. Juliet Lumati: You know, it's estimated that 133 million people worldwide face financial catastrophe as a result of seeking healthcare or paying for healthcare. And this actually increases the probability of people falling into poverty. Globally, healthcare is largely unaffordable for people that live in LMICs, low- and middle-income countries. I came to Ghana for the first time as a sub-I, doing a rotation in the surgical oncology ward. And that was the time I really began to understand what the healthcare system was like in Ghana in terms of the National Health Insurance Scheme, founded in 2003. And it was actually a really comprehensive scheme. In fact, Ghana has been praised for being one of the most equitable schemes in sub-Saharan Africa, because more than 60 percent of the population that's enrolled in the scheme are actually exempt from paying premiums. Yet in reality, in my experience, I saw that patients with the NHIS were not necessarily treated better. In fact, the pharmacies didn't actually accept the NHIS from the patients. Patients that did not pay for their care would sometimes have to sit in a ward until they can gather enough money to be discharged from the hospital. So the length of stay was impacted by people being able to afford to pay. So I really started to try to understand that, though there's been a lot that's been written in terms of the health insurance scheme and its ability to reduce financial barriers, in reality, what is the experience of the patients with the NHIS? My study was looking at the impact of the National Health Insurance Scheme on out-of-pocket expenditures and the risk of financial toxicity through a single institutional review at Korle-Bu Teaching Hospital. From that study, we followed about 200 patients over a six-month period that were admitted and discharged on the general surgery ward. We found that despite the NHIS, more than 60 percent of patients with insurance would still face financial toxicity, and this is for things like appendectomy or mastectomy, so these are some of the most basic surgical procedures, compared to the uninsured where 90 percent of the patients would actually face financial toxicity. And in fact, it's interesting when you start to dial down, what are some of the cost drivers? Anesthesia fees were not included in the insurance scheme. So how do you have surgery without anesthesia, laboratory tests, CT scans, patients will have to go outside to get these things and they weren't included. I presented some of my work to the National Health Insurance Authority and the Ministry of Health. And I asked them, Why is it that the cost of care is so toxic despite the fact that this insurance is supposed to provide financial risk protection? And I think you have to create a scheme that can capture the epidemiologic burden of disease in a country, not just looking at horizontal approaches: I'm just going to form surgery or HIV. What are you going to do when a patient needs a surgeon and is HIV positive? Within the scope of primary health care, you should have HIV screening, you should have primary prevention and treatment of cancers, you should have hypertension screening. But unfortunately, a lot of these schemes will say, We fund malaria. But if you need a surgery, emergency surgery, that could be life-threatening, we're not going to cover that.

[00:17:10] Dr. Rob Murphy: It's just amazing. People don't realize it. We have our own one-year, global fellowship called the HBNU fellowship, similar to the Glocal fellowship that you did. HBNU stands for Harvard, Boston University, Northwestern University and University of New Mexico. And we're always looking for people to apply for that, particularly in our own system of medical schools, but outsiders can also apply. I mean, I think it's the greatest program.

[00:17:36] Dr. Juliet Lumati: It changed my life. It really did. It took me as an early investigator, brought me on ground with four research assistants for a year. I went on all four surgery wards. Understanding, digging, analyzing, pouring myself into this health insurance scheme. And in fact, I actually signed up for the insurance myself so that I could figure out how it exactly works. So I think the length of time that is given with the program is very appropriate for an early investigator in a low- and middle-income country. You have to be on ground,you have to do the work, and that fellowship is designed to help and support you in doing that. 

[00:18:11] Dr. Rob Murphy: Let's talk about now. You're an assistant professor at Northwestern, you have protected time, and during some of your off-site time, you've worked at the Lakeshore Cancer Center in Lagos, Nigeria, where you've been a consultant for the last four years. Can you describe your experience and the research you're doing there?

[00:18:28] Dr. Juliet Lumati: So Lakeshore is the first comprehensive cancer center in Nigeria, so it's been in existence for over 10 years. There are several other centers in Nigeria that are private, and there's about 30 hospitals in Nigeria that provide cancer care. Lakeshore provides comprehensive cancer care. So screening, primary prevention, primary care, secondary prevention, treatment and surveillance.  They have a robust cancer registry of about a thousand patients that have come to Lakeshore for treatment, and they provide chemotherapy, radiation therapy, surgical care. We have a multidisciplinary tumor board that meets on a weekly basis, and we have pathologists, radiation oncologists, gynecologists, basically people from all over the world that sit on this tumor board, and we present patients and cases of patients in Nigeria. So I consult and I see patients remotely. I also spend some time on the ground as well. I am licensed to practice medicine in Nigeria.  And one of my goals is to really try to expand and build the research portfolio of Lakeshore. So Lakeshore is actually part of the African research and clinical oncology network which is an overarching organization of about 35 hospitals that provide cancer care in Nigeria. They have a partnership with Memorial Sloan Kettering, and through that partnership clinical trials, funding opportunities for trainees, training grants. And one of the things that I've been working on, for example, with our cancer registry at Lakeshore, is trying to understand what the actual average cost of getting cancer treatment. So we have a retrospective study right now, which I'm the PI on, looking at the cost of colorectal cancer, as well as breast cancer care at Lakeshore by stage and type of treatment. And then even on a bigger scale, I've spent the last 10 to 15 years writing about cost. I think we understand that the burden is there and the disparity is there. And I think I'm at the point right now as a researcher where I want to start thinking about interventions. So we actually have an ARGO [African Research Group for health economics working group, and one of the interventions that we're looking at is the role of a financial navigator in reducing financial distress, reducing financial toxicity and improving treatment adherence for patients. And the reason why I include treatment adherence is that there've been several studies, for example, the ABCDO study of breast cancer, and even one study at Lakeshore, that showed that 70 percent of patients that came to Lakeshore for consultation did not complete treatment. This is a very big barrier. When I think about my patients, I'd never lose a patient, right? If you don't want to see me, we get you a second and third and fourth opinion. We make sure you get treatment. So the cost of care, we believe, is contributing to the likelihood of patients actually completing chemo and treatment. And so our study is going to randomize patients to routine care as it is, which is no financial navigation, and another arm where you actually have a financial navigator that does financial literacy assessment. They'll come up with a financial plan for you. They will actually get you into the National Health Insurance Scheme of Nigeria and also work with charitable organizations in Nigeria that fund cancer care. And our hope is that this will start to make a difference in the rate of financial toxicity that we see, and that could potentially become a standard practice across cancer centers in Nigeria.

[00:21:42] Dr. Rob Murphy: It's a great plan and a great goal. Let's talk about surgery in general. Most guidelines for surgery are based on studies mostly done in the United States in non-minority populations. What are some of the ways you're working to improve representation of patient populations for these studies?

[00:22:00] Dr. Juliet Lumati: I think it's an extremely important topic. One of the ways that we are looking towards answering this question is potentially trying to build a practice pattern of enrolling patients in clinical trials in resource-limited settings. And not just social-sciences-based trials but treatment-based trials. For example, looking at patients with triple-negative breast cancer, what proportion of patients are getting immunotherapy plus standard treatment, and what are the outcomes of that? I think that many of our cancer treatments in lower-middle-income countries are informed by high-income countries, including the NCCN [National Comprehensive Cancer Network] guidelines. And so, part of my work is really looking at building a clinical trial portfolio to look at some of our standard chemotherapy regimen and how is that in practice in a resource-limited setting. And maybe there's things that we can learn. For example, can we omit oxaliplatin for treating colorectal cancer when that's not available and what's the actual planned outcome? In the U.S., I am part of a research collaborative. We are part of the Alliance Trial, which is looking at neoadjuvant chemotherapy for resectable cancers. There's been a lot of work done at Northwestern looking at bringing trials to communities. So you think when you build good science, people come. I think we need to figure out ways where we can bring those trials to the actual communities to affect the communities at large. We generally in my practice, if there's a trial that is applicable to a patient, we certainly open the door and enroll those patients in those trials. And I also think that diversity in the trial group makes a significant impact. I think the diversity also starts in the providers as well as the network of people that are actually helping to recruit these patients in addition to addressing the barriers to recruitment, such as transportation costs, some of the other variables. If they're struggling to actually even get to the care, they're less likely to want to wait around to hear about a clinical trial that's happening. Dr. Kischer and I are looking at a financial navigation program through our cancer center here. She's done a lot of work in the medical oncology practice to look at financial navigation. So, I'm hoping to use that as the basis to make the barriers easier for patients, so that when trials become available that those barriers don't become a barrier to actually enrollment for the patients. 

[00:24:17] Dr. Rob Murphy: Let's follow up with that in terms of surgeons themselves. I mean, the field of surgery is also very much lacking in diversity as other fields in medicine too. What are some of the ways that you think training programs can recruit and support trainees who are also from underrepresented communities.

[00:24:35] Dr. Juliet Lumati: This is something that I've been thinking about for a very long time. I mean, when I look at my training, I was the first Black female to have trained at Johns Hopkins in the history of Hopkins, in 2021 to 2023. And I think that when you look at the AAMC [American Academy of Medical Colleges] data of enrollment of underrepresented minorities, specifically, if you look at the Hispanic, Native American and African American populations, you see that overall there's been a steady rise in the enrollment of these populations in medical training. I think there are bottlenecks that have been somehow created in going from being a trainee to finishing residency and going on to fellowship and becoming an attending. So we have a vast majority of people that may decide not to do academic medicine and they miss an opportunity to engage with scholarly work. The other sort of bottleneck that I've been sort of thinking about is the attrition rates of underrepresented minorities in residency programs, and unfortunately, surgery still has a very high attrition rate. It's about a 25 percent attrition rate, so one out of four. But if you look at the data, I've published a lot on this, for minorities, it's about 40 percent attrition rate in a surgical training program that is seven years. So you have a 40 percent attrition rate and you only have one or two or three in the program at mass, that's half of the people leaving on a yearly basis. And people may be leaving for various issues, but I think one of the issues that I feel like has not been adequately addressed, we talk about starting with early education and getting people in high school. There's a lot of programs that are being done to like bring more people in, but I just think there's not a lot that's being done to support them when they get in. Some of these people are coming to environments they've never been in, right? You get into a small program in the middle of somewhere that you have no family, no relatives, no support. We know that it's going to be harder. We know you're going to be the first one. We know that you're going to have some challenges. We know that this is different, but how can we support you in making sure that you are successful in your mission to become the next academic surgeon seven or eight years after your training? So I think programs that focus on that retention is going to be the key to the future of keeping more of the people that decide to take this path to actually become faculty versus only focusing on building a pipeline.

[00:27:01] Dr. Rob Murphy:  Now I have one final question I'm going to ask you today, and I ask every guest that comes on this podcast: What advice do you have for young people who are just now embarking on a career in global health? 

[00:27:16] Dr. Juliet Lumati:  I would say that my biggest advice to young people is to first really know yourself and know what you're worth and know what vision of the world you want to grow and become. When I say that, I think about people like Paul Farmer, who said surgery is "the neglected stepchild of global health," a grand failure of global health to have not addressed this barrier for a very long time. Or when I think about when he's sort of being placed in places in the middle of nowhere, he says, just being in abject poverty and destitute and not having a plan that's going to work doesn't work for me. And I think if you're that kind of person that's driven by this idea that there is a neglect, a failure in our system to address vulnerable populations, I think you'll be fine. You know what you're looking for and you just have to build your community from there. I think what I see a lot of young people do is, Oh, I'm kind of interested in global health. And then I dab in and I dab in and, then I do this and I do that and I do seven different things. And that's fine when you're in the discovery phase, but I think to really be successful, you have to find yourself. You know, what is the thing that wakes you up at night? I know what those things are, and I keep doing them and I find places that I can do them at. And I think that's really the key is taking that time, whether it's gap years in your research time or doing a master's really figuring yourself out and figuring what's the thing that you get angry about every time you see it on the TV, or what's that topic when people talk about it, you just can't stop? And when you have that, those challenges you're just going to fly through, right? We talk about how difficult it is to get grants in LMICs, or like I wait two and a half years to get an IRB approved. You're only successful doing that because you're passionate. If not, there's so many barriers to working in these settings that it's very easy to give up if it's just something to do for the moment. But if you're committed and you're persistent and you know yourself, you scale through those barriers like it just doesn't exist.

[00:29:14] Dr. Rob Murphy: Well, Juliet Lumati, thank you so much. Appreciate hearing about all your incredible experiences, and I wish you the best of luck in the rest of your career.

[00:29:24] Dr. Juliet Lumati: Thank you so much, Rob. So great talking to you as well.

[00:29:27] Dr. Rob Murphy: Follow us on Apple Podcasts or wherever you listen to podcasts to hear the latest episodes and join our community that is dedicated to making a lasting positive impact on global health.