The Power of Community Medicine

This episode features Dr. James Allen, the founder and CEO of Health Systems Thinkers. Dr. Allen went from being a small-town physician in upstate New York, to working for a company in Borneo and later Bangladesh. In the process, he became one of the foremost authorities on community medicine. Being in a remote small town made him see the workplace as part of the community.

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Dr. James Allen:
I am a big fan of data. Data is critical. I think it's critical to talk to the people and understand what their true needs are.

Dr. Daniel Kraft:
Welcome to Healthy Conversations. I'm Dr. Daniel Kraft in Healthy Conversations Today with Dr. James Allen, founder and CEO of Health Systems Thinkers. So we have a time honored tradition on Healthy Conversations of highlighting the work of physicians who've taken a somewhat different course. You certainly have a very interesting pathway. You went on to do some really interesting work after you were a small town physician in Upstate New York. So I guess my question to you is how did you initially step off the sort of standard medical trajectory in the early '90s?

Dr. James Allen:
Just by chance, a recruiter called me asking if I would consider occupational health positions elsewhere. Going through the list of locations, which I kept rejecting because I was quite happy where I was, she finally said, "Well, I even have a position in Borneo." To humor her, I said, "Well, go ahead, tell me about Borneo." And about four months later I was there.

Dr. Daniel Kraft:
Number one, be careful what you ask for. Number two, when you first landed in Borneo, contrast Upstate New York with what you had to deal with when you started your work in Borneo and later in Bangladesh.

Dr. James Allen:
That was a winter of a lot of heavy snowfalls. I was on call one Saturday. The town crew had to come and dig my driveway out so that I could go to the hospital. On the way to JFK to fly to Singapore, they were closing the highway behind us, each exit as we went along. Then I ended in this tropical paradise where the weather varies between 78 Fahrenheit in the night and maybe 94 in the day. In terms of clinical practice, had fewer patients. So I could spend a lot of time with each one. But I also had many additional duties. One was overseeing the care delivered by a fairly large Indonesian medical team, offshore and onshore in Borneo. Of course, I didn't speak Indonesian and few of them spoke English. So that was a learning curve. That industry that I was supporting, energy industry, the potential for major disasters is ever present. So I was on call 24/7.

Dr. Daniel Kraft:
This sort of gave you an introduction to occupational health in the community setting, and now you're one of the foremost authorities on community medicine. So I'd ask you to sort of define that for us and your current role in how you engage with larger enterprises who have care delivery challenges in remote parts of the world.

Dr. James Allen:
Well, thanks for the generous adjective there. I'm passionate about community health. So I started in a small town and then I began to see how it could affect care in groups. The workplace is part of the community. Then over time I realized that really to try and change health, if I could get to even larger arc through influencing how people invest in care, in systems of care, then that could be even more impactful and satisfying.

Dr. Daniel Kraft:
Well, I think now there's a lot of more understanding that health is social. Does that tie into this community medicine thematic?

Dr. James Allen:
I'd look at it from a different angle as well. I came back to the United States in late 2015 as Rip van Winkle basically, waking up to this different health care system. A lot of verbiage and work to try to deliver care through teams. But that's where I had started actually. Community care in that sense was delivered through a team approach, working with medics and all levels of staff. That's was a necessity in a place like Borneo. But then community care also extended to the environment in which we were in. The water quality, the air quality were very relevant to my practice. I had to learn a great deal quickly.

Dr. Daniel Kraft:
So one of the adages of progress is often you get what you measure. I guess the question would be how do you measure community health and some of those other sometimes soft elements that contribute to social determinants, et cetera? You've been doing some work in partnering with the Institute for Health Metrics, for example. So what are the metrics that you've learned are important and what you need to measure or what we could measure in better ways?

Dr. James Allen:
The Institute for Health Metrics in evaluation has the largest repository of health data in the world, and much of it is freely available. But if I want to try to measure the effectiveness of community health, I would want to know maternal morbidity and infant morbidity and mortality, under five mortality, growth curves, education curves, because I think that's a component of health. There's also of course the human development index from the WHO and the World Bank has used. I would get some of the data from that institute, IHME.

Dr. Daniel Kraft:
How do folks find the Institute for Health Metrics?

Dr. James Allen:
Their website is healthdata.org. It opens up into just a incredible library of data.

Dr. Daniel Kraft:
So even before you took this path to Bangladesh and beyond, you were doing interesting work, but this helped catalyze your launch of something called Health Systems Thinkers. Maybe highlight for us how that evolved and what does Health Systems Thinkers focus on?

Dr. James Allen:
You've mentioned Bangladesh. When you build a new facility like a gas plant, which was happening in northern remote Bangladesh, it was my job to assess the health care resources in the community and also the health hazards. I would do that by meeting with the community. Of course, I did my research as best I could before then, but it was only through talking to the community that I learned what their real needs were. They weren't always in the data. You'll never guess what the most critical, most important thing the villagers told me when I asked them what they wanted help with.
It was when you're in labor and the baby's not progressing, you have to have a C-section. You get on the back of a wooden rickshaw and ride down a rocky path for two hours to the main road and then for three hours on the main road to a hospital. Could you help us with that? I never would've learned that had I not gone into the village and talked to people. When wealthier communities, organizations, corporations want to invest in lower middle income countries, I think it's critical to talk to the people and understand what their true needs are.
I'm a big fan of data. Data is critical, but data isn't always everything. So that's part of the recipe for what I created with Health Systems Thinkers is a process for getting information from the community in a 360 degree way, and combining that with robust data like IHME provides.

Dr. Daniel Kraft:
Western innovations trying to impose themselves on less advantaged communities. You also led work as Chevron's Asian Pacific Medical Director. Did you learn how to bridge the gap between the Western mindset and applying a solution to what folks really wanted, in this case timing of obstetric interventions?

Dr. James Allen:
Yeah. The anecdote in some ways that illustrates the point of listening first. In my experience of Asian cultures, that's rewarded with greater collaboration and trust. In that way, I was able to bridge what I had in terms of Western expectations and biases going in with what I learned on the ground.

Dr. Daniel Kraft:
As I understand it, a lot of what you're doing with Health Systems Thinkers is taking larger organizations, being the listening element to understand what the pain points and needs are, and then matching that, whether it's with dollars or partners and solutions that are needed. Help us understand the market need for that around the world.

Dr. James Allen:
Corporate social responsibility is I think a noble concept, but I think it can be distorted and in many cases is very ineffective. It gets a bad rap because of those things and it can look like whitewashing or buying influence. So when you say I want to understand the donor or the corporation's pain points, I actually want to know their core purpose. Why do they exist? So I'm going to seek for that in the dialogue with a corporation or donor first. There's one organization of about 200 U.S. multinationals who want to do good. It's called CEOs for Corporate Purpose. It's been around for maybe 12 years, 15. One of the co-founders was Paul Newman.
In their annual survey of 2020, 2021, 144 companies reported donating an average of $5.6 million a year for social improvements including health in their communities. So that's about a half billion dollars. My question is, what was improved with that? How are the improvements measured and how transparent were those investments? So that's what I'm trying to get at with Health Systems Thinkers is build a pathway for that to happen.

Dr. Daniel Kraft:
Can you give us a bit of a case study where that's been implemented?

Dr. James Allen:
I've been participating in one in Angola where we are asked to redesign the health care system for a province of 800,000 people. Not really a practical undertaking, but looking at their data and meeting many times over many months with community members, we were identifying about 14 different options for ways to improve health. We realized that with the agreement of the community, the most impactful system change would be an improvement in how maternal care was delivered. In fact, one of the issues for their workforce that made it difficult for them to retain workers in this remote area was the health care for their families, including obstetric care. Angola had a terrible maternal mortality rate, and especially in that province, that province was the second worst in the country. So they adopted a plan to completely revise and upgrade the maternal health system.

Dr. Daniel Kraft:
We know here, even in the United States, we're not doing so well compared to some of our compatriots in maternal and fetal outcomes. So there's ways to go, which sort of begs the question, any sort of takeaways and experience that you've seen leveraging technology?

Dr. James Allen:
Our idea with the remote sites, the primary care sites for maternal care was that we'd use more mobile technology to build the database and also set up alerts. I have been advising a small company called Lifeguard Health Networks which tries to get data out of the home into the health care system much more efficiently. Sort of empowers not just the patient because sometimes patients are incapacitated, but the whole team at home to communicate better and more effectively with better data points. That same concept was what we were aiming at in Angola. I'm not certain, Daniel, but I'm questioning whether some of the barriers in the United States are that there are already existing systems that don't work well as opposed to some places in lower income countries where there's nothing to start with and there's a cleaner start.

Dr. Daniel Kraft:
Yeah. You don't have the barriers of clinician lobbies and hospital systems and other infrastructure, so you can do things with a bit of a fresh start using much more advanced technologies. Even a simple mobile phone, there was text4baby, for example. It doesn't always seem to be fancy tech, but certainly the mobile world is advanced and even in rural America or rural Africa or Asia now, we're narrowing the digital divide through platforms like Starlink, et cetera.

Dr. James Allen:
Oh yeah, I mean, the race is on. I have some concerns about, I mean, is this a Wild West in terms of how some of these tools are being distributed and used and in terms of governance of some of the data and so forth. But I have no doubt that the digital divide is going to be closed.

Dr. Daniel Kraft:
Did you see much resistance in cultural changes to bringing some of these emerging technologies to more distant communities?

Dr. James Allen:
Actually, I saw the opposite. Often these tools are embraced more readily in lower income settings, maybe the novelty, but also the ability suddenly to communicate where previously you might have to wait to see if a doctor or visiting nurse came around once a week or once a month.

Dr. Daniel Kraft:
I recently launched a platform called digital.health. It's a website and a hub for professionals to discover health technology solutions that you can search for and leverage today, let alone tomorrow. So I'm always curious about any favorite needs or challenges that you think need to be still solved for?

Dr. James Allen:
Well, I think in designing a digital tool, if there isn't consideration about equity upfront, and it's very hard to build it in later. So if I could imagine a digital health tool that was a house, I would like the entrance way to have the tools and capabilities to maybe assess for different inequities. Maybe there's my health literacy, the user's willingness or trust in the tool, so whether they're actually going to engage or whether they're sight or hearing impaired, or if there's a connectivity problem. I would want all those things kind of assessed and adjusted for in the front end of a tool, so that actually makes the tool more effective.

Dr. Daniel Kraft:
I think there's an opportunity for folks who are building digital health solutions to sort of design them for better health equity, whether that's the right language, the right culture, the right education level, but the user interface and design thinking can make it much more approachable and utilized.

Dr. James Allen:
Yeah. If that was based on the individual user as they initiated use of the tool, then I think that'd be clever.

Dr. Daniel Kraft:
So any other sort of big picture elements, things we haven't covered so far, you want to put a finer point on?

Dr. James Allen:
I don't know if this is a finer point or broader point, but the mantra that I used in Asia for my clinicians was get out of the clinic, to understand and engage with the broader world outside the clinic. I think that can have a very positive effect and is interesting and fulfilling. I come from a primary care bias. That mantra was helpful for me. Since we've been talking about technology, the other mantra that I would like to share is high tech, high touch. As we experience a world with more and more powerful tools and more and more complex ethical issues, caregivers are given an opportunity to show compassion and respect on an individual basis. We need to find a way to continue to do that.

Dr. Daniel Kraft:
I love that you've got a background in internal medicine, public health, occupational medicine, tropical medicine, and beyond. That's where care happens. So thanks for joining us on Healthy Conversations.