Equity in (Local) Global Health

Whether at home or abroad, healthcare workers are constantly encountering patients and colleagues of varied and sometimes unfamiliar backgrounds, requiring continual growth in their cultural humility, language equity, and resourcefulness in collaboration. Join us as we learn from the unique first-hand experience that Dr. Lisa Camara and Christopher Chow have had in the Seafarer’s Medical Clinic, a Honolulu-based outreach that serves fishermen in need of healthcare when their ships dock to deliver their catches.

Learning Objectives:

1. Define cultural competence and cultural humility, and contrast the two concepts.
2. Apply the strategies of the guests’ unique clinical model to one’s own local underserved patient populations and healthcare system.  
3. Strategize how to find and collaborate with local community groups and non-profit organizations in one's region to improve patients' access to healthcare.

Credits:
Guest: Dr. Lisa Camara, Christopher Chow
Co-Hosts/Co-Executive Producers: Dr. Pooja Jaeel, Dr. Maggie Kozman
Executive Producer: Dr. Tammy Lin
Associate Producer: Dr. Candace Sprott
Senior Producer: Dr. Dirk Gaines
Editor/Assistant Producer: Joanna Jain
Production Assistant: Ann Truong
Website/Art Design: Ann Truong
Music: Chris Dingman https://www.chrisdingman.com

One of our guests uses the term “provider” to refer to their clinic’s physicians. Though this term is used interchangeably by many in the medical community, The DEI Shift podcast team endorses and supports the use of “physician” in place of “provider” where applicable, as outlined in ACP policy. For more information, please refer to the article included in the Show Notes.

Connect with us on Instagram at @thedayshift.pod and via email at thedayshifthealthcare@gmail.com

Transcript

[00:00] PJ: Welcome to The DEI Shift, a podcast focusing on shifting the way we think and talk about diversity, equity, and inclusion in the medical field. I'm Dr. Pooja Jaeel, a Medicine/Pediatrics practicing physician here with my Co-Executive Producer of The DEI Shift...

[MK] Dr. Maggie Kozman, a Medicine/Pediatrics dual hospitalist. Today, we're excited to bring you an episode that blends two topics that are close to our hearts, immigrant health and global health. In this episode, we'll be talking about a very unique clinical model that provides much needed care to a group of underserved patients in Hawai'i. And we hope to draw out for our listeners, some broadly relevant strategies from this model that can be applied to many of our own clinical practices and communities across the U.S. and the world.

[PJ] In residency, Maggie and I had an elective rotation we could choose to do called Thinking Globally, Acting Locally that focused on applying global health concepts to our local communities and to our close neighbors in Tijuana, Mexico.

[MK] Yeah, it was such a wonderful idea behind that elective, and although my rotation unfortunately got thrown off by the start of the COVID 19 pandemic right before, it had to take a different form than I initially expected. But I still got to actively think about global health issues and work on updating the preparatory information and self reflection exercises that we had for our trainees in our institution who were going to be participating in their own global health rotations in the future.

[PJ] Yeah. So we want to start that conversation and that thinking off for our listeners. And to help us do that are two really special guests who are going to be talking to us about their special clinical setting. So please help us welcome Dr. Lisa Camara and Christopher Chow. So Dr. Camara is an internist specializing in ambulatory care. She's been practicing for 20+ years with a large multispecialty medical clinic located in Honolulu, Hawai'i. And Christopher Chow is a clinic volunteer at the clinic we're going to be discussing today. He completed his undergraduate studies in public health and is currently working in healthcare quality and patient experience with a local health organization in Honolulu. Thank you so much for being here and sharing your experiences and tips from your clinical practice!

[MK] Yeah, thank you both!

[LC/CC] Thank you so much, guys. We are so excited to be a part of this podcast. Thank you.

[MK] Awesome. We like to keep things casual here on our podcast, so in addition to asking you both to call us by our first names, we'd like to ask if it's okay with you if we call you by yours?

[LC/CC] Yes. Please. Sounds good.

[PJ] Great, thank you so much. So before we get started talking about your unique clinic model in Hawai'i, we'd like to ask each of our guests on The DEI Shift to share something with our listeners about themselves. This can be something like a hobby, a favorite food, a meaningful experience, something that gets us to know a little bit about you and your background. We like to call this A Step in Your Shoes segment, and it helps us flex our cultural humility muscles.

[02:47] PJ: So Lisa, would you like to start and share with us something about you and something that makes you you?

[LC] Yeah. So kind of in line with the Step in Your Shoes theme to this component of the talk, I describe myself as a runner, although I'm late to find that passion in my life. I started running after I had both my kids, who are now in college. And now it's– I recently completed my second half marathon and I'm training for a full marathon. No better place to run year-round than in Hawai'i with great weather. And my running route takes me close to the beach. It's just a great way to get exercise. I'm finding it helpful more for my mental health nowadays than for my physical health. But it's just a joy and a passion for me.

[MK] That's awesome. I'm very impressed, and running by the beach is definitely, probably the best scenario for me, even though I don't enjoy distance running.

[PJ] But that's inspirational because I hope to do that one day, but it's always so intimidating jumping into it and seeing all those miles.

[LC] I'm enjoying doing it with my, uh, oldest daughter as well. She just did the half marathon with me. Of course, she whipped my butt, but we both did manage to finish relatively close together, so I was pretty proud of that.

[MK] As you should be! That's awesome. And how about you, Chris, what would you like to share?

[CC] Yeah, so my name is Chris Chow. I was born and raised here in Honolulu, Hawai'i. My last name is Chow, so I'd like to say I'm a big foodie. I'm really appreciative for all the good food we have here. I should get into running like Dr. Camara, but in the future. In the time being, I enjoyed the food, and my favorite food here is poke, so a raw fish dish. You know, raw fish is cubed up and put into a bowl, and there's so many different ingredients, and I think it's a good representation of the different cultures we have in Hawai'i. You know, one spoonful, you'll see all the different things that you may not see in other, uh, you know, countries or states, so I think that's what I appreciate about Hawai'i, how diverse we are as a state, and also the good food and good people and culture we have.

[MK] That's awesome. I like that picture of, sort of like the raw fish version of the melting pot, the way that that represents the community.

[05:16] PJ: Let's start with having you describe the Seafarer's Medical Clinic and how this clinic was started. Chris, do you want to go first?

[CC] Yeah, for sure. So the Seafarers Medical Clinic was started in 2016. It was started by one of the local churches in Hawai'i, the Waipio Baptist Church. They recognized the need that these fishermen present with, and one of the needs that was recognized was the need for health care and accessible health care. And through the church, the pastor reached out to his contacts, and one of the contacts he reached out to was Dr. Craig Nakatsuka, our medical director, who really kind of spearheaded the movement to recruit medical doctors, health care professionals, and students to form the clinic as it is today. So in 2016, it started and we're celebrating seven years, I believe, and Seafarer's Medical Clinic is a free medical clinic. And we provide basic medical care to the immigrant fishermen population in the Honolulu Harbor area.

[PJ] Congratulations on seven years! That's huge.

[MK] Yeah. That's really amazing.

[PJ] Have you been with them from the beginning, or when did you start?

[CC] Yeah. So I joined when I was a junior in my undergrad studies at University of Hawai'i. I joined about two or three months into the beginning of the clinic. So, uh, when the clinic started, they had really successful experience with the Filipino fishermen population. And they learned that the different populations out there– they noticed that the Vietnamese fishermen are a large population out there too. So they were looking for Vietnamese pre-health students who were interested in volunteering. And that's when I got that email through a pre-health club I was in at college. And I am ethnically Vietnamese. My Vietnamese speaking skills at that time were not that great, but I, you know, I learned to tap into my roots and learned how to, you know, communicate. And I think for the most part, be exposed to the culture, but yeah, so I joined in 2016 and I think it grew so much and just really quickly, if I can share more about the. Most of the fishermen come from countries including the Philippines, Indonesia, Vietnam, and also Pacific Islands, which includes Christmas Islands, Tonga, and Samoa. These fishermen come here typically on two year contracts, which means that they leave their families for two years and they come to Hawai'i and they catch a lot of the main fish that we eat in Hawai'i and also export. This includes ahi tuna, mahi mahi, manchang, and all swordfish or marlin. And these fish are sold commercially at the auction house here in Oahu. And I learned that this is the only auction house in the United States that sells ahi, that sells, uh, yellowfin.

[PJ] I think that's, that's really interesting. When we were kind of chatting a little bit and hearing about this clinic, you were telling us about something unique about their immigration status and how limiting that can be in terms of how far they can kind of travel in the U.S. Could either of you talk a little bit more about that?

[CC] Yeah, thanks Pooja for bringing that up. So, like you said, due to their really unique immigration status, the fishermen are not allowed to leave the pier area. They typically live on the boats, and they have their clothing, food, and shelter, all their basic amenities and needs are pretty well taken care of by their ship owners or their captains who kind of initiate that transition from their home to Hawai'i. But we learned that healthcare is sometimes a challenge just because for the captain or boat owner to take out the fishermen outside of the pier area, extensive paperwork and periods of waiting has to be taken account of in order for the fishermen to leave the pier area. So that's something that Dr. Nakatsuka and the church recognized as a need. So to kind of resolve that need, the Seafarers Medical Clinic created a clinic right on the pier so that the fishermen do not have to leave the pier area or have, you know, have to engage in that paperwork process to receive basic medical care.

[MK] That's really incredible, and this is so interesting to me because this is, you know, a patient population that I would never have even thought of realizing existed, and they have obviously many socioeconomic and cultural barriers, but even just the physical limitation of not being able to leave the pier is not something that, you know, is something we are familiar with when we are, you know, going about our normal day to day clinic for the majority of us and our listeners, so I think it's really beautiful to see, you know, the local community respond to a need that they identified, or actually, that was maybe not even something they took the initiative to identify necessarily, but something that came into their awareness and, you know, and began to fill in that gap.

[CC] Thanks, Maggie. Yeah. I think before I got this opportunity to volunteer, you know, like I said, I enjoy eating poke and you forget, you know, the people that go behind catching the fresh fish. And like you said, the type of work is very labor intensive, you know, a lot of uh, physical movements. And, uh, when they go fishing, they go out for at least four weeks out. So, uh, during four weeks, you know, they're out in the ocean and sleep is limited, you know, and they're working all these long hours and when they get back, you know, they're unloading the fish and resting for some time. And it's just a cycle, right? And if I may mention, they're really sacrificing their wellbeing for their family. Most of the fishermen have families back home. A lot of them have children and they love to share the success stories that their children are able to, you know, exceed in like college or building a family or building a house and all of that's possible because of, um, here fishing, you know, they send, if not most, all their monies back home, uh, since, you know, food, shelter, and their necessities are taken care of by their captains.

[PJ] Right. So really supporting their families from here. That's really beautiful. Yeah. Can you tell us a little bit about what medical services the Seafarer's Clinic is able to provide in the limitations of being kind of confined to the pier area?

[LC] I'll take this one if Chris doesn't mind. Chris was talking about setting up a clinic, but allow me to paint a picture of what that actually is in reality. So as Chris was saying, the fishermen aren't allowed to physically leave a very small area around the pier. It's fenced and it's guarded. So twice a week, the volunteers of Seafarer's will set up folding tables and chairs. We have about four to five folding tables and ten folding benches that we set up. And that is it, that is the reality of our medical clinic. So there is no brick and mortar structure at all. Everything is carried in, um, in tubs that we have to open and set up every week. So with this kind of scenario in mind, this obviously limits the extent of the medical care we can provide. What we do is a lot of blood pressure checks. We do screening for diabetes. Or for those rare individuals who come to us with a diagnosis of diabetes already, we can check their blood sugars. And then we assess and evaluate various musculoskeletal complaints, as you would imagine with very hardworking fishermen. And skin things are also pretty common as well. We recently expanded our care to include a volunteer vision testing organization. So that van comes once or twice a month and they will do vision checks and examine the eyes. So that's an additional thing that we've recently added to our repertoire.

[MK] That's great. And it's really helpful to just have you paint that picture for us to envision, you know, the realities of what this looks like and the challenges that inevitably come with this. And I mean, some of these challenges will overlap a lot of global health work when any of us in the countries that our listeners are joining us from end up doing any kind of global health efforts, whether it's more from providing direct medical care, providing assistance with medical education or public health interventions, there's a lot of different challenges in building trust, in dealing with logistical challenges that come up with, you know, space limitations and resource limitations and, and then trying to build rapport. Can you share either or both of you about some of the ways that you've found helpful to build trust and connection with this particular patient population and some of the challenges that I'm sure you have encountered in the process?

[13:57] CC: I think that's such an interesting question. I was thinking about an answer, but I think it's a loaded question. And I think one thing is time and sincerity and having an open mind. I think time is so key in building the relationships with the fishermen and having them understand what you're doing there, you know, what your mission is. And also for us to understand what's meaningful for them too. If I can like, uh, go back in time, one of our first projects was for us to get to know the fishermen. So, you know, we know nothing about the fishermen and they don't really know much about us. All they know is that somebody wants to set up a clinic. So we started at first an assessment form. So we printed an assessment form to get to know what the fishermen, you know, what the population consists of, their background history as much as possible. So, you know, of course, their age, their social history, their habits. And also, like one question I'd like to focus on is what does health look like to them? You know, what do they think their health looks like? What does healthy look like considering all the different factors? You know, like their amount of sleep available or, you know, the type of physical work they do. We want to learn that. What healthy looks like for them and what we could do to help them get to that point. It's really interesting also to learn what health care looks like in their country before they came to Hawai'i, what kind of health care they had access to. And, you know, a lot of them mentioned to us, you know, we would ask, like, "Oh, have you had a family history of blood pressure or hypertension or diabetes?" And a lot of times the answer would be, "I don't know," because, you know, in that village or country or that area that they're from in their country, they may not have access to Western medicine, like the type of medicine that we're practicing here. So it's really interesting to see what health looks like to them. And also for us to help us understand what they need to get healthier and in their perspective. And also to know the factors that are involved in their health. It's a high stress environment sometimes, considering that they're separated by their families. You know, a lot of the time when they're not working, they're spending their time talking with their families on FaceTime on the phone, right? And when patients are seeing us at the clinic, a lot of the time when they're waiting, they're, you know, FaceTiming with their families and showing us their kids, right? And that's something to take account of, the factor of being separated from their family. Sometimes, uh, sleep is sometimes a factor too when they're fishing. Smoking and alcohol is also sometimes included in a lot of the fishermen that we work with. So to answer your question about how we build relationships, I think it's important to remember it takes time to share with us what healthy looks like to them and have us share with them what we could do to help. And if I can add one more thing, it was really interesting asking the patients what, you know, health care looks like in their countries. They were mentioning money is a big issue, right? Especially when they're in rural areas. A lot of times money is a big factor and whether they can get the health care they need. And one of the biggest questions for us is "What does that look like for financial obligation?" And we would say, "Nothing." And that's something that took a while for them to understand. And you know, even a year or two after our clinic, we would get fishermen coming in, you know, who had been fishing on the piers for some years, and we would ask them, "Oh, you know, thank you for coming for the first time. May we ask what had you wait for two or three years before seeing us?" And they would say, "Oh, I always thought I would have to pay money" or something like that. So just for us to understand where they're coming from and what health care looks like and, uh, you know, in their home country, and how that differs or how that's similar to what we're providing.

[PJ] I think that's such a great example of, I mean, you guys are already physically meeting these patients where they are, but also emotionally, socially, culturally trying to really understand who they are, where they're coming from. I really like the question of "What does healthcare look like?" I mean, we talk about "What does health look like," but healthcare, I think, is a really unique question to ask. And it sounds like it's given you a lot of different information. That was going to be something that I was going to ask, is the kind of level of suspicion that maybe folks come in with, knowing that they're getting free healthcare and what the, you know, quote-unquote "catch" is. So thank you for touching on that already.

[18:31] PJ: I also wanted to ask a little bit about the language barrier and the both kind of health literacy and literacy level that some of these patients are coming in with and how you all overcome that.

[LC] So it really depends on the country from which the sailors originate. We find that the Filipino fishermen are pretty good in speaking English, but Indonesian, Vietnamese, and the Polynesian Island sailors have very little. We rely quite a bit on volunteer translators who come to the clinic twice a week. We have translators who help with Indonesian, Vietnamese. We haven't yet found translators for Kiribati or Tongan or Samoan. A lot of our student volunteers are also bi- or trilingual, and that helps quite a bit as well.

[CC] I did want to, um, echo what Dr. Camara mentioned about translators, and I wanted to elevate, uh, the translators just a bit, just because, um, they do so much more than the language capability, which we are very thankful for. But I learned that they are really the glue or the liaison between us and the fishermen. The fishermen, we rely on the translators more than just language, but the translators we work with are people in the community, uh, friends of friends who are usually from that country or speak that language. And also more importantly, they can connect culturally with the fishermen. So most of the times, the fishermen would have an interaction relationship with our translators first, and our translators would use that relationship to introduce the clinic, um, if there's any healthcare needed. And the translators would provide, you know, more than just translation, but just somebody to talk to for the fishermen. I can imagine like a boat, you're in the boat with the same six people; just talking with somebody else other than your, your boatmates from the same country, you know, and providing that kind of ear. Or even like sharing food, you know, like a fisherman may have a craving of an ethnic food that one of our translators can cook at home and bring, right? So you know, the translators in the church that we work with, they really provide that social support, spiritual support, and I think it's one of the key factors that makes this clinic so successful, that relationship. I think, Maggie, back to your point, how we build those relationships is with people who can connect with the fishermen as people and, uh, you know, with the same culture and similar, um, upbringing.

[LC] That's such a good point, Chris. A lot of the sailors call the translators "Auntie." The "Aunties" will give us background information about the sailors, about what their families are doing, or what their life is like on the boat, or what they're really trying to, um, ask us, but are afraid to ask us. Um, so yes, Chris is absolutely accurate in saying that the translators are key to developing rapport with a fisherman.

[PJ] And it sounds like they're also key, I mean, in providing a lot of mental health support as well. I mean, you all mentioned the blood pressure and diabetes and everything, but going hand in hand from what we're hearing, there's seems to be like a lot of mental health concerns with being in isolation.

[LC] Right. Quite a lot. I mean, they're separated from their families, they're lonely. But there's also tragic and traumatic things that happen while you're out at sea. Last month, we were talking to some fishermen whose boat had actually sunk, and they required rescue by the Coast Guard. Another boat caught fire, and apparently boat fires are not as uncommon as I had originally thought. Sometimes there's violence on the boats too, where they get into fights just because they're in such close quarters for such a long period of time. So yeah, there's a lot of mental health that goes on there as well. And the translators are key with giving us that information.

[MK] Yeah. I think it's so key, like you said, the fact that these people who are volunteering as translators– yes, they bring the language equity component, yes, they bring literally greater voice to the patients themselves, um, as patients, but also as individuals – but just bringing in the stories that maybe they, the patients wouldn't be able to share in a limited clinic time, being able to really utilize them as members of the multidisciplinary team in a way that maybe we don't always default to in our typical clinical settings, but really remembering the importance of translation services and language equity as we try to provide care for all of our patients, regardless of what country we're in, whether we're in our home countries or traveling abroad and trying to provide short or long-term healthcare services to others who speak different languages than we do.

[PJ] So we've touched on this concept a little bit, but just wanted to dive into it a little bit more explicitly, but when we're working with patients across different cultures. We think about important concepts like cultural competence versus cultural humility. So I wanted to ask you both to please, um, kind of describe these concepts and how they apply to the work that you do with this patient population.

[LC] Pooja, that's a great question. I'd like to answer it from my own personal experience with cultural humility. I'll backtrack and say that I'm a relative newcomer to the Seafarers Clinic in comparison to Chris. I've only been volunteering for about a year. My daughter and I are both volunteering there. She's a nursing student. And I have to say that coming on board, no pun intended, I had a certain framework of what to expect from working with immigrants. And that was brought to the forefront very clearly for me. Um, and I'll give you a very simple example. One of the fishermen in some of my early encounters asked for medication for seasickness. I was very surprised and shocked, and I'll say with some embarrassment now in retrospection that I was like, "You mean sailors get seasick too?" And I, I had, I really had no framework for what they do out in the ocean. I mean, it can be quite tumultuous. These are people who live their lives on the ocean and for them to get actually seasick, it must be really terrible conditions, but I didn't have a framework for that. And so once I kind of processed that and thought about my reaction, I really had to check myself and say that there was some, some definite bias on my part, and I have to be a little bit more open in how I treat these people fishermen.

[MK] Yeah. Thank you for sharing that vulnerably. I think we all can probably identify times in our clinical and nonclinical lives where we've had similar experiences and really had to take a step back or had someone call us out, or the new term of "call us in" to say, "You know what, that was actually some bias there that you didn't realize in yourself." And so I think just your willingness to share that exhibits cultural humility and this idea that we're never going to master another group's culture. You know, cultural competence and cultural competency, that term from kind of the 1960s and 1970s that was sort of earlier on in, in our efforts towards equity, especially health equity. It's been a useful concept and refers more to the ability to knowledgeably engage with people of different cultures, but sort of carries this connotation of like, "I'm now competent in your culture and I am fine now, I don't need further training or I'm, I've eliminated my biases" and you can almost sort of master another person or group's culture, but it doesn't really allow for growth and the humility that one has to maintain in order to acknowledge that there's more that you can learn always about another group or culture. And also cultural competency as a concept doesn't really allow for intersectionality of identity. And so cultural humility is sort of a more fluid, dynamic, and lifelong learning process that we teach more now in the medical context to our medical students, but also to ourselves, to people in nonclinical contexts, and focuses on exactly what you have been Lisa, your own self-reflection on your biases and how to, with curiosity, sort of listen and learn.

[LC] It continues to be a growth process for me, for sure. Every time I go to the clinic, I run up against something in my own self where I'm like, "You know, I should probably have addressed that in a little bit more open way." Chris and I both live and practice here in Hawai'i, which is a melting pot of many Asian cultures. So I think we felt pretty comfortable going into it with at least a baseline knowledge of the cultures that we're dealing with, with the fishermen. But when you're face to face with a sailor, with a fisherman, it's, I found out very quickly that I didn't know as much about their culture and what they came from than I thought I did. So it's always checking my assumptions at the door and trying to go on with an open mind and treating each individual with respect and really trying to listen to them.

[MK] Absolutely, and you bring up a great point that you know I think at least for me when I hear cultural humility or competence, I think about racial and ethnic diversity and racial and ethnic culture, but you're talking about like occupational culture as sailors, and like a very different life or work experience than the one that you have. There's, you know, like the culture of people's hobbies, the culture of people's families, the culture of people's political grouping. So just to encourage us to kind of think more broadly about what cultural humility means, not just racial or ethnic differences.

[PJ] Yeah, it's really focusing on that lived experience and how it can really differ for so many people that we do have stuff in common with. But I really like that you both were able to start with some common ground and then kind of build up from there and kind of value the differences, but also highlight some of the similarities as well with your patients.

[28:36] CC: Yeah, I just wanted to echo Dr. Camara's emphasis on cultural humility. You know, like Dr. Camara mentioned, every clinic, every encounter, you learn something new about the different fishermen and the cultures that they come from. And I think the key for cultural humility for me is that it takes time and an open mind. And also it's a two way street, you know, for us as volunteers and professionals or, you know, the medical professionals there. We are not only teaching the fishermen, but we are also learning, you know, their culture and, uh, where they're coming from. So we would, of course, be sharing, you know, information on any medication or conditions we're talking about, but they're also sharing with us how they would treat something back at home, or, you know, maybe different remedies that they also have. So it's really interesting to kind of learn what that health looks like in their view. And also it sets us in perspective. I think something that's part of cultural humility I picked up was to be grateful and not to take things for granted. Just learning the different values and their situation in general, you know, like how they're able to thrive and make the best of the resources that they have available, just brings humility to a different level. Like before going to clinic, I may have like a silly complaint of "It was so hot today. I was so tired and so irritated." And just learning about the fishermen– they're working all day on the boats and they come to us and are getting their checkup and, you know, they're just so happy and smiling, right? It just puts things into a different perspective that when you leave clinic, it's like, "Oh, that little complaint I had is not relevant anymore."

[MK] That's really lovely, I like that a lot. And I really appreciate too, that you shared, Chris, um, not only are they sharing their experience and then learning some of the, you know, medical care or recommendations that the volunteers are providing, but they're also sharing with the volunteers how things are treated in their home country, and this idea of like what is healthy to them and what does healthcare look like to them. And that's been one of the best things that I have been in the process of learning with my own global health experiences, is "What about this other population or country where I'm serving can I bring back home that may be a better way to approach things than what we're doing?" Even if it's not, you know, the hottest new study that's come out that was likely only based on a Western population or a very limited patient demographic that doesn't apply to the patients I'm trying to serve in another nation. "What can I bring from that country that might actually be more applicable to my patients here in the U.S. than some of the guidelines that may or may not be based on a similar grouping of patients?" So really adjusting my mindset to be less about "I'm bringing things to others," whether it's like a local immigrant population that is here in my home clinic or hospital, or what am I bringing to people in another nation, versus "What can I really just humbly learn from them and then, um, apply to my own patients?" And this kind of pulls in, in addition to the concepts of cultural competence and humility, the fact that a lot of work has been done more recently to reassess global health efforts with the lens of equity, anti racism, and decolonization. In particular, the American Academy of Pediatrics– you know, Pooja and I are Med/Peds so we have our ear to the AAP a lot!– The AAP has collaborated with the Association of Pediatric Program Directors and the Consortium of Universities for Global Health here in the U.S. And they've actually created and piloted a curriculum called GHEARD, G-H-E-A-R-D, which stands for Global Health Education for Equity, Anti-Racism, and Decolonization, in order to reframe the way that global health trainees and physicians and other allied health professionals from historically colonizing regions like North America and Europe conceptualize and implement our global health work. And so I actually had the chance to join one of the virtual Beta-testing sessions for the curriculum in 2022. And I learned so much, and it was really a wonderful experience getting to learn with people from all over the world in this virtual setting. And it's definitely influenced my own global health efforts since then. The formal curriculum actually has officially launched, and members and nonmembers of the AAP can access it for free on the AAP website, so we'll include the link to that curriculum in our Show Notes. I started looking into it a little bit and it already looks really great and even further than some of the Beta-testing sessions that I was part of. And if anyone is seeking more training in this area, as I was looking at the website, I saw that the AAP is offering a virtual reality training module on Equity and Anti-Racism in Global Healthcare, which you can pay to access on their website as well. And if you're wondering, I do not work for the AAP or get anything out of this free marketing. There's just really not a lot of actual curriculum in this area, and I'm really interested in curriculum development, so getting to see formal curricula on decolonizing global health is really exciting, so I wanted to share with everyone.

[PJ] Thank you.

[33:39] MK: Alright. So shifting gears, the Seafarer's Clinic has ties to multiple community groups and organizations, it sounds like. And I know the founding church was obviously really important in its inception, but how did the church and then the clinic then expand those connections to other nonprofits in the area? And maybe what are some ways that we as listeners can build similar partnerships in our local communities?

[CC] Definitely. Thanks, Maggie. I think, uh, word of mouth is a huge component in this, and considering Hawai'i is a relatively small and tight knit community, you likely have more connections than you know before even talking about it. So I think word of mouth has definitely helped the clinic expand. Our doctors share with their colleagues and, after a long clinic or hospital days, they come to our clinics at nighttime to volunteer, which we're very thankful for. And most of our volunteers are students, right? So, we do have word of mouth connections with health groups at the universities here. So we're very thankful for our students coming to support our clinic, in between work and also studying. But yeah, word of mouth is really big, really helps us connect with different pharmacies, and even the vision connection that Dr. Camara mentioned earlier, and also different nonprofits that have been helping us like the Shiraki Foundation through the Church, and Lions Club, and the Rotary Club who support in different ways to help our clinic.

[PJ] I think one connection that I actually wanted to explore a little bit more is, um, I guess with the either local or federal government, how your clinic was able to get past that restricted area and even set up shop on the pier in the first place. What was that like?

[CC] Yeah, so we are very thankful that we are included in conversations with the Long Line Fishermen Association. So there is an overall board of association that kind of manages the fishermen that are coming in and out of the harbor and catching the fish. And we do have a voice in those decisions. So we are thankful to be included in their decision-making process. So it has been taking some time to, you know, like you mentioned Pooja, get access to the pier, but with their help we are working with them, and we're more involved in the conversations with the decision-making process with health and screening. If I may mention, COVID was huge, you know, the fishermen, the fishermen world did not stop, you know, the fishermen continued to go fishing. We still needed to eat, and fish still came in. So with that said, I think that was a huge all-hands-on-deck. So the Long Line Fishermen Association worked with us, and we collaborated with different health partners, such as Kaiser and other nonprofits, who really all-hands-on-deck provided vaccinations to interested fishermen for COVID. And I think that's a perfect example of everybody working together for one cause, right? To keep the fishermen happy, healthy, and also to keep that, you know, that economy running through continuing that fishing industry. In addition to COVID vaccinations, we did have certain resources available like tetanus boosters available, tetanus vaccinations for fishermen who, you know, may have got caught by rusty equipment. Recently, the Department of Health partnered with us to look at hepatitis prevalence in our fishermen population. So that has been very recent and, you know, with the help of the translators and the Department of Health with their education resources, we were able to share more about hepatitis with the fishermen. And for those that were interested and willing, they went through a series of testing through blood and also to see if they were eligible for a hepatitis vaccination. Those are some examples, the COVID, hepatitis, and tetanus projects are examples of multidisciplinary work that we're doing with the Department of Health, with the Long Line Fishermen Association, with the fishermen, and also the boat owners, the captains as well. Just to do all that what we can to help the fishermen and their health.

[PJ] Wow. Yeah. It sounds like lots of relationship building, lots of longevity in these efforts together. And I think if I were to kind of highlight, it sounds like ways that we can translate that into our own local communities, it sounds like it's very important to continue to build these partnerships over time, to really bring back the like evidence of what these efforts are doing back to the folks in the community centers and back to the volunteers. Any other lessons that we can bring back to folks who are trying to build these connections in our local communities?

[LC] I think it's important for us to just always be aware of potential connections that might benefit our clinic. Just as one example, that's how we got the vision truck. The truck driver was somebody I knew through my practice, and he had mentioned that he was doing this as a volunteer. And so it was pretty easy at that point to just make the two things connect and happen. So we're always looking for those potential avenues to explore where we might benefit. Preceding when I started, um, it was a much larger collaboration with different churches because the spiritual fellowship aspect was very important in bringing and attracting the fishermen to the clinic. The different churches would kind of rotate responsibilities to provide the fellowship components, but also provide food for the fishermen. And then the clinic was kind of an offshoot of that. So after the pandemic, we are trying to rebuild that component of it, get more collaboration from different community resources, which would include some of the local churches, and to work on drawing in more fishermen again.

[MK] That's really amazing. I love to hear, you know, there was the, the spiritual health component that was part of this and actually maybe one of the foundational services that was being provided when the clinic was started.

[LC] That really, really appealed to me because, um, it's, it's looking at the, the fishermen in their entirety, right? So they're addressing the spiritual and community aspect of their health, the fellowship component, and then almost as an afterthought, the physical health care. So it's really holistic healthcare at its very fundamental grassroots level.

[MK] I love that. I like that idea of, you know, the baseline is the spiritual health, and the physical health is like icing on the cake on top.

[40:17] PJ: And then we've already started talking about the volunteers in general, but I wanted to ask a little bit more about the medical volunteers.

[LC] So the volunteers are highly organized and very well-trained. Having said that, there's lots of supervision from physicians. We are always on site. And Chris has been spearheading the organization and training and kind of standardization of the volunteer cohort, which is quite large. It's so large, in fact, that we have a waiting list of students who want to join, and we're taking it on a case-by-case basis. Because we have too many volunteers at this point.

[PJ] Can you tell us what the trainings look like, Chris?

[CC] Yeah, just to, thanks Pooja, just to kind of echo Dr. Camara, we're very thankful to have dedicated medical providers and also um, students who dedicate their time to come Tuesday and Friday nights, you know, two times a week, a lot of times. And Friday nights are not nights that college students would want to volunteer, right? But you know, that's needless to say the dedication that the students have. And a lot of these roles kind of evolved over time and throughout the seven years. I think we're always working on improving the workflow of the clinic. And we do have a pretty structured training system that lasts maybe five or six months or so, but we recommend students to spend a set amount of hours per role. So we start off with the pharmacy role, then the vitals role, then the scribing role, and just to make sure that the new students are good in building up their skills and knowing the resources that they have available in the clinic.

[LC] The volunteers also have a council. This is a relatively new thing for them. The council is comprised of the more senior volunteers. Our current council includes our volunteers who have recently been accepted into medical school. So they are transitioning out of those roles in the volunteer clinic and moving into their new, future roles as medical students. And this council does a lot more organization than what Chris has just told you. There's an educational component, which they entirely drive, which is about medications and basic pathophysiology if you can believe that. It was astounding to me. They make new volunteers study and then take a test before they're allowed to pass on to the next role.

[PJ] That's incredible. Wow.

[MK] That's awesome.

[LC] So they're tested on what medications do what. Blood pressure medication: is it a diuretic? Which one is a beta blocker? It blew my mind when I saw that. In addition to that education component, they do like social things together to kind of build camaraderie and collegiality. So there's beach events and stuff. And as Chris mentioned before, we're in the process of planning a seven year anniversary event of some kind. So the structure of the volunteers is truly amazing. Truly one of the most remarkable things about this clinic.

[MK] That's really impressive. These are pre-med students, y'all, and they're talking about what is a diuretic versus a beta blocker!

[LC] And in detail! They go into detail! The lecture lasts an hour! An hour!

[laughter]

[PJ] So well set up for their first year of med school.

[MK] Yes, for sure, for sure. That block is gonna be super easy in first year of med school.

[PJ] But it sounds so special that these folks who've already moved on, they're starting to transition, are still sticking around and passing down their wisdom and trying to make the clinic better and make the experience better for everyone. So that's, that sounds like you create a really special experience and cohort and clinic.

[LC] It's amazing. It's really amazing.

[MK] Absolutely. And just the strength of training and, you know, making sure that everything is done safely and appropriately and with the supervision of the physician. They're just good principles anytime that we're taking care of patients, but especially when we're engaging in care of patients who are underserved and from different backgrounds from our own and may not necessarily be able to advocate for themselves, or when we go abroad and scope of practice and rules may be different than where we trained and where we practice. Just always making sure that we're operating within our training and then asking for help when we need it. I think that's been one of the biggest things that I've learned in my own personal experiences too.

[44:43] MK: Alright. Well, thank you both so much for taking the time to share with us all of the important work that you have been doing with Seafarer's Clinic. I know our listeners and Pooja and I have learned so much. Is there any one last pearl or takeaway that you would each give our listeners about a lesson you learned while working with this sort of local/global population that you're taking care of in the clinic?

[LC] Yes, as I said, I'm relatively new to this. It was really eye opening for me and really kind of refreshed my passion for medicine because this is healthcare stripped down to, to its core, to what brought us into healthcare in the first place, which is taking care of the entire person in a respectful, culturally sensitive way. Stripping away all the EHR and the paperwork and the In-basket hits every day. My blood pressure, I feel is already going up as I say those things, but really spending time to, to focus on, on the person. And I found it to be so invigorating to myself personally, but also bringing that passion back into my practice as well. So I'm very grateful for this experience, and I would recommend anybody out there listening to also think about volunteering.

[MK] Hmm, that's great. Chris?

[CC] Yeah, for sure. I think on behalf of pre-health students, I think we're all very grateful to have an opportunity where we can get hands-on experience in the clinic, whether that be, you know, taking a blood pressure or, you know, taking a patient's glucose. And I think to echo Dr. Camara, it's really about building that relationship. You know, with medicine and health, that relationship is so important. I think at the pier, we're able to kind of go a little further than that, you know, beyond the 15 or 20 minute block that you may have with a patient and just talk to them about their family and, you know, what brings them here. And I think that's what motivates us as pre-health students to going towards that next step, which is maybe med school, nursing school, physician assistant school, whatever that may be. Just remembering what, you know, Dr. Camara really highlighted, the core of health care. Making those relationships and, uh, bettering individuals as much as you can.

[PJ] Ah, I love that you both highlighted the relationship aspect and reconnecting with patients, reconnecting with our passion. Such a great way to end and thank you for leaving us with those lessons. So that's all the time we have for today, but we'd like to invite our listeners to join the discussion online and share your stories and experiences with working with an immigrant patient population or global health experience. You can send that to us over email at thedeishift@gmail.comor on Instagram and Twitter with the handle @TheDEIshift. That's the D E I shift. We will also have a transcript of this conversation along with Show Notes that include the resources discussed today. Thanks again to our guests for joining us and to our listeners for tuning into this conversation. Don't forget to claim your CME and MOC credits at ACP online and see you next time.

[MK] Thank you so much, Lisa and Chris!

[LC/CC] Thank you. Thank you.

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