Being in the Room Where It Happens: Loan Repayment and Global Health

By Sriram Shamasunder, Co-Founder of the HEAL Initiative

Global heath, at its core, is about equal lives having equal value. Over the last few decades, we have made incredible strides on preventable mortality and have started strengthening health systems around the world. To push even further in the coming decades, Global Health will have to seriously grapple with its colonial roots that continue to shape the whole field. Diversity, racial and economic, lives on the frontlines, and of course with our patients but are often on the fringes in the halls of decision making.

This will entail grappling with the question: Who gets to set the agenda to improve the lives of the poorest billions? Who is in the room where it happens?

Democratizing evidence, structural competencies to understand structural forces that cause poor health and inequity are all ideas that are here to stay.

Similarly, at the institutional level as well as at the regional, country, and international levels, we need a diverse workforce who have cut their teeth doing work proximate to suffering to take up leadership positions to shape the Global Health conversation and agenda for decades to come.

We are more or less familiar with the statistics: The United States will become a “majority-minority” nation in the next 25 years. In 2017, less than 6 percent of U.S. medical graduates were black — even though African-Americans account for 12 percent of the U.S. population.  America’s doctors-in-training lack socioeconomic diversity. Between 2007 and 2017, more than 75 percent of medical school graduates came from households with annual incomes of more than $75,000 a year. Only 5 percent came from the bottom quintile, or up to $24,000 a year.  The statistics go on and in sum, paint a picture of a very un-diverse physician workforce taking care of an increasingly diverse country. From our experience, physicians entering Global Health careers tend to further skew towards being affluent and white. This risks exacerbating the voyeurism and white savior complex Global Health is so prone to replicating.   

Even when first generation college goers, URM (underrepresented minorities in medicine) and indigenous health professionals make it through medical school and residency, they often do not choose Global Health equity work.

We know that they often struggle from disproportionate debt. We know that efforts like the NHSC lead to retention in the work, and better health outcomes. One way to bring those first-generation college goers, URM, and indigenous health professionals into Global Health equity work is to offer Stipends for Loan Repayment.

Being proximate to suffering informs how health professionals think about health systems. Large amounts of debt make it less likely that early career health professionals will consider more rewarding but less lucrative paths that will shape their entire career and the likelihood to work with underserved populations.

HEAL, a capacity-building, two-year immersive fellowship is offering Stipends for Loan Repayment specifically for indigenous, URM, and first-generation college goers. The offering is a nascent pilot but attempts to prove that there are many who would be attracted to a deep commitment to underserved communities if not for the debt. Can we draw a generation of US Doctors into Global Health work by offering serious loan repayment?

Time will tell. Meanwhile, it is one step in diversifying our workforce who are committed to serving underserved populations, both in the United States and internationally. It is an important step in bringing a generation into Global Health equity work who are often not included. It is a necessary step in changing who has a seat at the table as Global Health agendas are shaped. Changing the face of who is in the room where it happens when it comes to Global Health agendas!

In commitment to this effort, the HEAL Initiative is offering two $25,000 Stipends for Loan Repayment in addition to a PGY4 Salary, available to Rotating Fellows of the 2020 cohort who are (1) American Indian/Alaskan Native, (2) URM, and/or (3) first generation in their family to receive a university-level degree. Learn more about this opportunity here!

Sriram Shamasunder, MD, DTM&H, is an Associate Clinical Professor of Medicine at UCSF, and co-founder of Heal Initiative. He completed his Internal Medicine residency at Harbor UCLA. He has worked extensively in Rwanda, Liberia, Haiti, Burundi, and India. In 2010, he was named an Asia 21 fellow as well as the Northern California Young Physician of the Year.