Sarah Berry // This interview series features educators, scholars, artists, and healthcare providers whose work is vital to the growth of the health humanities. On Friday, November 6, I interviewed Ms. Elsie Essien, MPH, about her work as a global health expert in cross-cultural care, her doctoral work, and her passion for creating fabric art.
Sarah Berry: What are you working on?
Elsie Essien: I’m a doctoral student at the University of Maryland School of Public Health in health services research, which is a mix of public health, health economics, biostatistics, policy, and health equity. It’s like a soup or salad of so many different fields, and the aim is to use evidence-based research to inform policy. Another aim is to help practitioners provide better healthcare using the evidence that the researchers have come up with. Oftentimes there’s a lot of economic modeling that we do, which is interesting for me. I studied health economics a little bit when I was getting my Master’s in Public Health at the [State] University [of New York at] Albany, but this is a whole new ballgame with learning how to build economic models to inform policy.
I’m mainly using statistical packages in ways that I haven’t used before.
At my last job at Northwell [Health Systems], I was involved in several different research projects, but we left the data analysis to statisticians. So I think I became a little bit over-reliant on making sure that I have someone who can analyze the data for me, whereas in grad school, I have to create everything from start to finish. You have to analyze your own data. So that’s been the challenge of it. One of the courses that I’m taking is health econometrics, which is a mix of statistics and economics. It’s my first time building statistical models to analyze my data.
SB: Can you describe your work at Northwell?
EE: It’s the largest healthcare system in New York. They are based in Long Island, Westchester County, throughout the city, and Queens. They have a smaller footprint in the Bronx, but they do provide some services there.
I worked at Cohen Children’s Medical Center, which is a tertiary academic children’s hospital within Northwell Health. I started off as the program coordinator, and then later on I was promoted to be the program manager for GLOhBAL (Global Learning. Optimizing health. Building Alliances Locally), a global health program in the Department of Pediatrics. As the program manager, I work closely with Dr. Omolara Uwemedimo. She’s a pediatrician as well as a clinical researcher, and my job was to co-lead overseeing the leadership direction and administration of the Global Health training program. We train resident physicians in the pediatrics department on how to provide ethics-based, culturally competent care internationally, domestically, as well as locally through global health clinical rotations. So locally, we focus on providing care for underserved children populations, including vulnerable children of the Three Affiliated Tribes (Mandan, Hidatsa, and Arikara Nation), unaccompanied minors, immigrant children, and low-income children. Abroad, we work primarily in Kenya and India, but we also had an affiliate site in the Dominican Republic.
As the program manager, having a background in public health, I contributed to the team by bringing my public health knowledge to these medical settings. Sometimes clinical providers focus on the individual or treatment aspect of health care and end up missing the population health piece in terms of thinking about social determinants of health. What are the things outside of the clinical setting that they need to be mindful of when they’re providing care locally?
I supported the team by supervising the residents in the global health track and then also collaborating with the faculty to plan and facilitate a biannual, pre-departure global health preparatory knowledge and skills boot camp, and what the boot camp was focused on was how can we provide training to physicians who work in the US and have access to almost all the resources that you can think about, and then send them to Kenya, or another resource-limited setting, where providers and residents from Cohen who participate in global health rotations don’t have access to all those resources (i.e. certain medical equipment, tests, medical personnel). Some of the questions we pushed residents to think about are, “How can you be innovative in a resource-limited setting? How can you improve your clinical history skills or your exam finding skills?”. And after they finish, we bring them in to debrief on what they learned from practicing abroad that they can implement in their own clinical practice back in the US.
What was fascinating about that experience is oftentimes when residents came back, they would realize, “Okay, I don’t need to order all these tests. I don’t need to practice defensive medicine. All I need to do is focus on the patient and the patient- provider relationship.” I co-led lectures on cultural competency and on cross-cultural care as part of the global health pre-departure preparatory boot camp. The objective of my presentations was to educate resident physicians on providing care to diverse populations, moving beyond cultural competency to think about structural issues like structural racism within the healthcare system, community, and society that impact health outcomes. For example, I focused on structural biases within the field of medicine itself and worked with clinicians to ask, “How can I, as a clinician, not just put myself in my patients’ shoes, but also how can I admit that I have biases and understand how that affects how I practice medicine?”.
SB: Can you provide an example of one of those trainings that went really well? [Warning: this segment addresses infant death in Kenya].
EE: One resident immediately comes to mind. So prior to residents going [abroad] they always had a pre-departure debrief with me. While they are abroad they debrief with me every single week. And when they come back, they have a post-departure debrief with me. During one of the pre-departure preparatory trainings I mentioned before, I was paying attention to what one resident was saying and doing and he brought up the issue of the “Third World,” and he was showing a sort of savior mentality, you know, and during our boot camp there was an exchange between him and another resident. She explained to him, “First of all, we don’t use the term ‘Third World.’ What used to be ‘developed’ and ‘developing’ is now termed ‘high-income’ and ‘low-income.’” These are highly politicized words that we use in health care.
Before he traveled on his rotation he had a pre-departure debrief with me. He had a very negative perception of Kenya and healthcare in Kenya. So he felt that he would be able to provide more to them than they would be able to provide to him. While he was in Kenya, during one of our weekly debriefs he shared with me that there was a newborn that needed to be resuscitated at the hospital earlier that morning. We were talking through his experience of that moment, what was going on in his mind, what providers were there with him, the child’s condition, etc. He said, “Yeah, you know, I was telling everyone, let’s do this. Let’s do that. And I felt that they weren’t taking the situation as seriously as I was. And I was wondering, ‘how can they [the local Kenyan providers] behave this way?’”. I let him speak, and then later on I explained that in certain settings, especially in low-resource settings, we have so many babies who are dying. So you can’t spend all your resources on this one child because that child might die. And then the second child and third child might die because you’re focused so much on the first one. So you have to make some ethical decisions about who gets to live and who gets to, unfortunately, die.
So he came back to Cohen with a new perspective on the clinical challenges and ethical decision making that clinicians and providers have to make in resource-limited settings. Before going, he wanted to go into a pediatric specialty after completing the residency program, but because he went on this trip and he engaged in the Global Health Program, he decided to go into primary medicine, which was so different from the path that he had envisioned for himself prior to going to Kenya. It’s those situations that make me realize that the work that we’re doing is impactful because not only did he realize, “Okay. I got a lot from going abroad, like they taught me how to be a better physician, and I taught them how to fill in the knowledge gap,” but also he realized, “I’m not just going there to be a savior abroad.”
SB: That’s so valuable as a transformative experience with an impact on global health practice. It’s also important about attracting more physicians to primary care because it’s still an understaffed area of medicine, right?
EE: Yes, it is. It is. There’s research out there comparing US-trained physicians and foreign-trained physicians—international medical graduates who receive their medical education outside of the United States or Canada—that examine factors that contribute to whether a physician chooses to pursue a career in primary care, a specialty or sub-specialty. There is evidence that oftentimes trainees who are educated in US medical schools [graduate with so much debt] that they tend to go into specialties that are lucrative. They’re thinking, “Primary care is important, but I’m not going to make as much money.” So there is definitely a shortage of primary care providers in the US, due to that, and other important reasons.
SB: Can you speak about your preparation for your position at Northwell and your development of cross-cultural care expertise?
EE: When I was a student at William Smith I studied abroad in Pietermaritzburg, South Africa, and that experience laid the foundation for where I am now. I still communicate with my friends that I made in South Africa—we video chatted yesterday! When I studied in South Africa, two of the courses that I took were a clinical psychology course and an abnormal psychology course, and what fascinated me the most was I remember we spoke about schizophrenia and different mental disorders and how mental health is seen completely differently in different countries. So I think that in South Africa, there was this concept of sangoma, a highly respected traditional healer. I remember my classmates and professor mention that that are instances when people have schizophrenia, they don’t say, “Okay, this person has a mental illness.” Instead, they say, “This person has a special power. He is able to see visions and see beyond this realm.” And I thought that was fascinating. And I realized, “Wow, I need to be mindful that people experience diseases and illnesses differently.” This reminds me of a book I read in undergrad and in my Master’s program called The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures by Anne Fadiman.
And I think also for me [this realization had a special relevance] because I’m originally from Ghana. My family’s from Ghana. So growing up, when I was sick, my parents veered toward the traditional medicine before they’d go toward Western medicine. Even that practice has changed since we’ve been in this country for many years. Increased exposure to Western medicine tends to make one trivialize, shame, or demonize traditional, complementary, or alternative medicine. The argument is that there isn’t a lot of research on those practices and fields to validate the efficacy of those approaches. However, there are some modern medicines that contain components of some of the medicinal herbs that are used in other cultures. At Northwell, during one of my visits to south India, I had a meeting with a physician and clinical researcher who focuses on using alternative medicine to treat autism.
Going back to my experience of what laid the foundation for developing my expertise in cross-cultural care, after I came back from South Africa, I wanted to explore more about how culture impacts health and healthcare, and then I was starting to make more connections from my own experience [growing up in the US]. I’m often just lumped in a big group of black people. It’s convenient for reporting and developing solutions on a macro level, but it’s also inconvenient. My experience of illness might be completely different from someone who looks like me, but who comes from Haiti, or someone who looks like me and who is Afro-Latina. So I started to think, “How can I educate myself and then educate other people so that they don’t ‘other’ people who don’t look like them or overgeneralize the experience of people who look similar. In addition to my cultural and racial/ethnic identity, how can I be seen as an individual with unique experiences that impact health outcomes and my concept of health when I walk into a physician’s office? How can I help clinicians and providers to realize and understand that there are some questions that they can ask a patient to appropriately grasp what they’re experiencing at the clinical level, given the limited appointment time and patient-provider interactions, which you may not get if you simply put patients in a generalized box?”
To prepare myself for this work, related to my role at Northwell, I knew that I could simply say, “Okay, I’m culturally competent because I’ve traveled to different countries, understand the immigrant experience, and have a good grasp of diversity issues.” But there is more to it; I think that it’s an ongoing process. To attain cultural humility, one has to have unremitting exposure to different cultural encounters, and to challenge oneself to move from having an ethnocentric worldview to developing an ethnorelative worldview. While I was working at Northwell, I decided to take additional courses at the University of Albany, SUNY, School of Public Health Center for Continuing Education. I earned the Advancing Cultural Competence (ACC) Certificate, which aims to provide recipients of the certificate with the knowledge and tools to promote cultural competence in the public health and healthcare workforce. Obtaining the certificate enabled me to know what vocabulary to use when discussing issues related to cross-cultural care, structural inequities, and what it means to be structurally vulnerable in society, and to know how to unpack different [cross-cultural issues]. I also learned how to relay the information to people within the public health and medical fields and outside of the health care field, so that I’m not just coming in and saying, “I’m going to give you an anecdote.” Instead, I can actually provide clinicians with existing evidence. The course covered issues on current challenges and sociopolitical barriers to health, community activism and being a health advocate, historical frames of oppression, trauma-informed care, narrative humility, the issue of “deservedness” in health care provision, and clinical cases related to cultural competence. The course focused on a variety of health issues among structurally vulnerable groups such as Native Americans, African Americans, immigrants, labor migrants, incarcerated people, Latinx people, and the LGBTQI community. It covered a whole realm of issues and connected them with the structural issues that impact health and wellness, which I found very valuable.
After earning that certificate, I presented the idea to my supervisor to include in the learning materials that the global health program offers to residents. So we revamped a previous equity health curriculum and created a separate elective within the global health program that focused on health equity and immigrant health. It was fascinating—we were able to teach cultural competence as a separate elective and not just as part of the preparatory boot camp. It was a great experience. We received amazing feedback from the residents.
SB: So much of your work involves global cross-cultural contexts and ethics, and then suddenly last spring, there were travel bans. The pandemic has also heightened xenophobia and racism in the U.S. And when the pandemic reached the US, you were in one of the hardest-hit areas, New York City. I imagine things just got real hairy real fast for you and your colleagues.
EE: Yes, it did! I’m trying to think back to what that experience felt like at the beginning of the pandemic. It seems so long ago, but it wasn’t. When COVID first hit, I was just coming back from completing a site visit at our partner hospital, clinic, and institutions in Kenya. I had a layover in South Africa and witnessed the airlines cancel flights to China with no explanation while I was in the waiting area. It didn’t really hit me that something was going on, but the airports were not as busy and my plane was almost empty. When I got back, as the pandemic progressed and we became aware of how the public health crisis would impact programming, particularly sending residents abroad on clinical rotations, we had to figure out how to pivot the Global Health Program in response to the domestic and international health crisis. It was interesting because two groups of residents traveled—one group to India on one of the program’s international clinical rotations and the second group to a reservation in New Town, North Dakota, on one of our domestic clinical rotations—a few weeks before the pandemic became a critical issue in the United States. We had to act very quickly in response to what was happening internationally and domestically, because we didn’t want our residents to be away if countries and states chose to close their borders. I tried to read international news to help me with my decision-making and to support and guide my team at Northwell regarding next steps. We worked with our international partners and Northwell network to bring the residents back home, and then we quickly transitioned our operations from in person to online. The transition seemed seamless because Dr. Uwemedimo encouraged us to engage residents remotely through Zoom for several years prior to the pandemic—that is how we conducted the debriefs I mentioned before—and I transformed our informational guides and resources to electronic copies when I first joined the team. I think that the residents were coming to me and telling me what was happening within the clinic and hospital.
For residents, faculty physicians, other providers, and leadership it was a very stressful and uncertain time because there were concerns about safety for patients, staff, and clinicians as well as the public health preparedness internationally, in the US, and within the health system. Northwell was a leader of the COVID mitigation plan within New York. I always enjoyed working for the company, and I was proud of being in the health system, but I felt even more proud to be working for Northwell because they were offering [coronavirus] testing early, and they were going into different neighborhoods throughout the city to assist with community outreach and public health response. Now they’re working with churches and community organizations to administer the flu vaccine.
It was a very trying time in healthcare, especially working in New York City, because in addition to tackling the pandemic there were protests taking place, and there was so much uncertainty. How we responded as a global health program was to not shy away from what was happening. So we created another elective, a pandemic curriculum focused on COVID-19 and also infectious diseases outbreak as a whole. I focused on the social determinants of health and the so-called cultural racial/ethnic minorities component of the elective to educate the residents on why some groups were more adversely affected by [both] the pandemic and the public health response (e.g. the inability for some essential workers from structurally vulnerable groups to quarantine or seek care if infected). We had residents who were moved by what happened to George Floyd and decided to participate in the protest as well as look into how to use their platform to become advocates. We had a resident who became interested in trying to help the undocumented children on the Texas-Mexico border who were being detained in hotel rooms at the beginning of the outbreak, and they lacked access to proper medical interventions if they became infected.
We (the Global Health Training Program team) try to use our platform to educate the residents on how can they get involved in these leading issues in real time. One resident who participated in our rotation at the Texas/Mexico border in the Lower Rio Grande Valley, Dr. Elsa Treffeisen, wrote an article that addresses transportation barriers to care for people living in that area. I can only imagine how a pandemic further complicates this issue. Another resident redefined her research design to examine how COVID impacts immigrant families in Queens and how she, as a clinician, can use her platform to be an advocate.
SB: The physicians’ actions to pivot during a pandemic is such a valuable mitigation for health equity. It speaks volumes to your role at the organization and the founding work that you did. Thank you, and I’d like to thank your colleagues for moving the needle on health justice during the pandemic. You came out of that hugely stressful time safely and entered grad school in August. What are you planning on doing with your PhD?
EE: There’s so much that I want to do with my PhD. Ideally, I want to go back to work in industry, but I also enjoy teaching.
What I realized from working in the industry is that there are so much untapped data that are important to include in public health planning and policy development. When COVID changed our program operations, we were creating a pandemic curriculum for a remote elective, and we found an article from 2018 that predicted that this was going to happen and recommended all the mitigation steps international and domestic leaders could take to make sure [a pandemic] doesn’t happen. And that study sits in an academic journal, and the general public and those who will be most affected don’t get access to it, so it frustrates me a little bit when I think about that issue. A lot of the research that we did as a program related to quality improvement at our partner hospital sites, primarily in Kenya. So whenever the residents picked a research topic we try to figure out how to better serve the community or help our partners better serve the community or improve health care provision, and hopefully health outcomes. By implementing evidence-based practices and improvements, you’re able to see real-world change within the hospital setting. For example, there was a study on the role of the home environment, maternal health, and adverse childhood experience and how that impacts developmental delays in children. That study enabled us to figure out the issues that the moms were having, how it impacted their children’s development, and how we could educate the nurses in Kenya to screen for those mental health issues.
Another resident’s research project examined barriers to continuous positive airway pressure (CPAP) administration for children in respiratory distress at the Kenyan hospital. Oftentimes children will be in respiratory distress, and they wouldn’t be placed on CPAP. So we tried to figure out the facility-level factors, provider-level factors, and caregiver factors that impacted whether or not a child was placed on CPAP. From the research findings, the resident proposed recommendations to the supervising pediatrician in order to help improve case management, treatment, and patient outcomes in the future. So when I think about all of those experiences, I think that within the industry, I don’t know if I’ll be able to change the world, but I’ll be able to make some real-world, tangible changes with the evidence and research data. I’m interested in applying health services research to improve health care quality and access.
SB: Thank you for explaining evidence-based cross-cultural care in the healthcare delivery world. Do you also have a creative side?
EE: Yes, I have been brainstorming and refining my business plan for my fabric designs for several years. Originally, I wanted my business to be a social enterprise focused on working with so-called low-skilled women and adults with developmental disabilities to help me with creating decorative throw pillows, but my end goal now is to focus on hospital interior design in Africa. When you walk into a hospital in the US, it really does make a big difference when you see the paintings on the wall, the fabrics on the chair, the upholstery, and the inviting environment based on the décor, especially at a children’s hospital. But when you walk into a hospital in a low-resource setting, oftentimes the waiting area has a long wooden bench or plastic or metal chairs. There’s no décor, nothing to invite you, and for some people, they see themselves as going to the hospital to die, not because of the décor but because of their health status and condition. I think about how the built environment impacts the healing process.
The environment matters. I mean, if I’m going to that hospital, I wouldn’t want to be there that long, either. So I’m thinking about how I can change my fabric design to be upholstery, to be used on chairs, wallpaper, etc.
Creativity keeps me grounded, hopeful, and balanced. When I first joined the team at Northwell, there was a resident trainee pre-departure handbook that was about 30 pages long. I read the whole document because it was my responsibility to be informed of the details so that I can advise residents as needed. Due to the length of the document, I would jokingly say that, if I were a resident, I would not read the 30 pages. Interestingly, it turns out that the residents weren’t reading the full document because they would come to me and ask questions that were in the handbook. One of the first projects that I worked on was to transform the handbook into a very colorful presentation slide and from there, to create an engaging handbook with pictures and colors, and then they read that handbook, and they accomplished what they needed to get done. Colleagues often expressed appreciation for the fact that I made it a more engaging experience for the residents. I used my creativity in ways that they weren’t expecting.
I think that creativity in global health is very, very important because in that field, I’ve heard people say, “Why aren’t you disillusioned?” or “Why are you still so hopeful when people are dying and living in dire situations?” When I was at William Smith [College], in a public policy course, I was looking into art therapy and how it can help people who live with HIV/AIDS. Let’s say you have a child whose mom passed away from AIDS, and she never talks, she doesn’t tell people how she feels. When you put a piece of paper and some crayons in front of her, she can draw for you what she’s feeling; through that, you can talk her through her emotions or trauma. That was a powerful lesson because we tend to minimize the impact of art.
Oftentimes, art and creativity are seen as just hobbies or something to push to the sidelines, but in health and in global health, it can make a huge impact. It can have a tremendous impact on people who just need a colorful painting to uplift their mood. So that’s why, even if I don’t need to include art or something creative, or write, I try to bring it in for myself because I know that at least I need it.
SB: Same here! You’ve got me thinking about how art provides a cross-cultural line of communication. As an artist and a global health expert, you’ve got a really rich lens on health, culture, and creativity. What countries have you visited, and what can other countries teach the US?
EE: For work, I’ve visited India, Kenya, Switzerland, Dominican Republic, and other nations. But in terms of the response to coronavirus, I think what India can teach us the importance of seeing yourself as part of a community. When the outbreak was happening, I was in touch with my colleagues in India and people were coming together to support each other. They were frightened about what was happening. But then they knew, “My action impacts my neighbor’s action. So if they tell me to wear a mask, I’m going to wear a mask, or if they tell me to stay at home, I’ll follow instructions, not because I think that it’s my personal right, but because what I do really makes a big difference.” And there’s a South African word called ubuntu, meaning, “I am because you are.” When I travel outside of the US, there is always a sense of community that feels missing [in the US], especially at this time with the election and how polarized the country is, like we don’t see each other as a community, we don’t see each other as neighborly; it’s always individual. If we value community more in the US, we can make great strides in ways that we can’t even imagine.