The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The CSA Committee on Global Health works to celebrate the volunteerism, philanthropy, and global health impact of CSA members, both locally and internationally. The committee would like to take this opportunity to highlight the accomplishments of Dr. Reema Sanghvi, the Division Chief of Global Health and Policy at the University of California San Diego (UCSD).
If you would like to be featured or to nominate a colleague, please email Dr. Ana Maria Crawford, CSA Global Health Committee Chair, at firstname.lastname@example.org.
An Interview with Dr. Sanghvi
Where did you grow up?
Do you think your upbringing influenced you becoming involved in GH? If so, how?
Almost certainly. Having left India at age 15, I had memories of poverty, death and disease all around me. I went to undergraduate school and medical school at the now defunct Honors Program in Medical Education at Northwestern. Having only practiced medicine in Chicago, Illinois, I wanted to know what it was like to practice medicine in India. In 1991, the year after I finished my residency training (also at Northwestern), I took a month-long trip to work with SEWA-Rural (Society for Education, Welfare and Action-Rural). It was so inspiring it launched my career in international medicine. This was a time before email. It took a year of “snail” mailing family friends and their contacts to connect to the charitable hospital in western Gujrat that was founded by an Indian couple. They were followers of Swami Vivekananda, an Indian philosopher, and believed that to serve the poor is to serve God. That was their motivation in setting up this charitable hospital, and eventually their community health outreach and training programs for youth.
How do you define Global Health (GH)?
I define Global Health as the health concerns of the humans on the face of this planet. Both terms are critical here. Global means just that, it means all of us, not them. And health is more than the treatment of disease.
What do you consider as your first Global Health experience?
At an impressionable age, in 1991, after having finished my residency, I worked for a month in what was then a small rural charitable hospital in India. I did an anesthetic with Ether for the first time, and rather than continuing to use Ether, I ended used up their entire year's supply of Halothane in a month. I lacked familiarity with Ether and with the Boyle’s apparatus through which it was delivered. It felt unsafe to use both a new drug and a new delivery mechanism, so I only did it the once. At least I could always answer “yes” to the inquiry of whether I had ever done an Ether anesthetic. Putting Halothane in the Boyle’s bottle allowed me to at least use a gas with which I was familiar despite this new-to-me anesthesia machine. In fact, in the local language, Gujrati, an anesthesiologist is referred to as the person who has you sniff the bottle.
Intravenous delivery tubing was too expensive for that hospital. So, in those days we used a straight needle in a vein with the arm uncovered and visible on a makeshift arm board to administer drugs. There was no pulse oximeter and no carbon dioxide monitoring. There were no EKGs or automated blood pressure cuffs. If I wanted to know the heart rate, I felt the patient’s pulse. If I wanted to know the blood pressure, I took it manually with a bulb sphygmomanometer. One time I did a spinal for a hernia repair. Ten minutes into the operation the surgeon, who was a young woman like myself, looked over at me with surprise and asked what I was still doing there. Apparently local custom was to pop in a spinal (with a reusable needle, in 1991) and then leave to go get some lunch.
I realized then how much our monitors contributed to anesthesia safety in the US, but also that it was entirely possible to do a safe anesthetic with minimal monitoring equipment as long as you were paying attention with vigilance to the rate and force of the pulse and the respiratory rate and pattern.
That is such a remarkable account! What are recent examples of your GH engagement?
I was just in Maputo Mozambique creating a partnership between the anesthesia departments of Hospital Central Maputo (HCM) and UCSD. We were well received and have great hopes for our future. They are in need of some clinical teaching in specialty areas, specifically the use of the ultrasound to perform regional anesthetics and the use of the video laryngoscope. They are very eager to create research collaborations to both inform their practice and for faculty promotions. We are excited to use the multitudinous resources of UCSD to further education and research at the residency program of Eduardo Mondlane University at the Hospital Central Maputo, the premier teaching institution in Mozambique.
What GH initiative or project are you most proud of accomplishing?
I co-lead the American Society of Anesthesiologists-Global Health (ASA-GH) committee’s involvement in the residency program in Guyana. The ASA-GH committee began as the Overseas Teaching Project with involvement in Rwanda (ASA-OTP). That morphed to become the committee on Global Humanitarian Outreach (ASA-GHO), which I joined in 2018. I was promptly made co-leader for our involvement in the teaching program at Georgetown Guyana. We co-ordinate with the Canadian Anaesthesiologists’ Society for International Education Foundation (CASIEF) to provide volunteers teachers for their residents. Covid-19 put the program on pause for in-person visits, but we are now accepting in person volunteers again. Volunteers work there for a minimum of two weeks.
How can Global Health evolve over an Anesthesiologist’s career from residency to retirement?
Global Health has in fact evolved during my career. We used to talk about humanitarian outreach or medical missions. Now we talk about partnerships and collaborations. I've also shifted from primarily short-term surgical trips to more long-term capacity building engagements. The majority of practicing anesthesiologists who have been involved in global health have done so under the auspices of a service provision trip with a surgical team parachuting in to underserved locations and performing surgeries on patients who would otherwise lack access. Such practices have come under scrutiny and have been roundly criticized for a variety of reasons, including the temporary nature of the work, the difficulty with establishing proper follow up for the patients, and the cost, which some argue could be used to build a new wing onto the hospital. This sort of engagement has been largely replaced by capacity building engagements with local anesthesiologists and surgeons, universities, clinics and hospitals. The intent is to offer resources that help local doctors develop their own systems so as to be able to serve their population.
What has been your most challenging or surprising lesson learned in Global Health?
That try as I do, I am not immune to "white savior" attitudes and the arrogance of being on the privileged side of the power dynamic even though I am neither white nor a savior. The most recent lesson I had in this was subtle, but telling. I was in Jos Nigeria with a urogynecologist, Ene, from LA. We were working with the local anesthetists at a center providing expert services to treat obstetric fistula. One of the scrub techs, a very sweet and friendly older woman, much like me, came to find me on our penultimate day to tell me she had a present for me. I was reluctant to accept, and “explained” to her that I came to Nigeria to give, not to receive, and that I could not accept her present. In hindsight, I was more condescending than explaining. Disappointed, she left. I told Ene about the incident. She informed me in no uncertain terms that I had made a mistake. The scrub tech had brought me earrings that her daughter makes. To turn that gift down was a very hurtful faux-pas. Ene reminded me that the only difference between me, the patients, and the staff was a geographical caprice of God. God had given me greater resources, and his people in Jos Nigeria fewer resources. Our worth as humans was the same, I wasn’t inherently superior to them. This happened four years ago, after I had been involved in Global Health for decades. It was a very valuable lesson Ene offered me about humility in the work I do.
What would you like to share with others regarding the value of Global Health engagement?
It brings meaning to my life. Doing this work privileges me to go new places, meet colleagues and friends and become a part of their lives, professional and otherwise. I consider myself very fortunate indeed. And when I feel a bit burnt out from my work in the US health care system, I feel renewed in my commitment to my profession by engaging in global health.