Q&A with Dr. Raj Panjabi, CEO of Last Mile Health

One of TIME’s 100 Most Influential People in the World in 2016 and the recipient of the 2017 TED Prize of $1 million, Dr. Raj Panjabi is a Liberian-Indian American physician, Assistant Professor of Medicine at Harvard Medical School, and a co-founder of Last Mile Health, an organization dedicated to bringing healthcare to rural communities in Liberia and around the world.

On Wednesday, The Daily Princetonian sat down with Panjabi to learn more about his work and his efforts to help build primary healthcare systems around the world. Panjabi urged interested students and healthcare professionals to join him and leaders around the world in this work through the Community Health Academy platform, which aims to open source community health best practices from around the world.

The Daily Princetonian (DP): Could you walk us through your whirlwind journey?

Raj Panjabi (RP): I grew up in West Africa since my parents migrated there from India in the 1970s. When I was nine, civil war broke out in Liberia. That set my family, and hundreds of thousands of others, fleeing. We moved to Sierra Leone and ultimately settled in North Carolina. We were fortunate as immigrants to be taken in by other families who helped us restart our life. The community that rallied around us had a big role to play in ensuring that dreams, that would have otherwise been destroyed by the disruption caused by fleeing war, didn’t get destroyed. Because of my parents’ persistence and because of that community, I had the chance to go to medical school. When I was 24, I wanted to go back to Liberia to see if I could serve the people we had left behind.

When I got home in 2005, what I found was just utter destruction. The physical infrastructure that you might imagine could be destroyed in a 15-year civil war was, indeed, destroyed. My school had been damaged; there was no running water in the capital. What was equally, if not more, painful was the human infrastructure we lost. So many people had fled the country and many had not returned. We had lost a generation of professionals.

We were left with 51 doctors serving a population of four and a half million people. Putting that in perspective, it would be like having eight doctors to serve the city of Washington, D.C. If you got sick in rural communities, where I was serving as a clinician in government clinics, you could die from conditions that no one should die from in the 21st century. We’ve lived for many decades with innovations in medicine. These innovations were simply not reaching last mile communities that were thought too hard to reach or too expensive to serve.

My father used to say that no condition is permanent, and it is a saying that comes from West Africa. My wife and I launched Last Mile Health with fellow health workers from Liberia and America in 2007 with $6000 from our wedding donations. We sometimes joke that it was either the most romantic or the least romantic thing we’ve ever done. Over the years, we’ve supported the Government of Liberia and a coalition of actors to launch a National Community Health Assistant Program, which seeks to employ 400 nurses and other frontline clinicians in rural community clinics and 4000 community health workers in remote communities. Increasingly, we’re doing similar work in support of other countries.

DP: You were based in America before you decided to go back to Liberia and start Last Mile Health. What were your greatest initial challenges?

RP: There were some practical barriers and some personal ones. The practical ones are how do you pick the right team, how do you define the right mission, how do you ensure that the problems you’re working on are truly the problems that the community is facing. Are we serving the real needs of people that have been marginalized? It takes a while to figure that out. We spent a lot of time listening to patients and visiting their homes. For four years, we tried a number of different projects. Then, following the data was really important. We found in our initial work with HIV that while we were able to bring HIV care to rural clinics, patients from rural areas were still the ones most likely to die or fall out of care. We interrogated that data to understand why that was happening. Sometimes, economically, the models aren't built to serve the micro-communities. What you need is a micro-model of healthcare to work alongside the broader healthcare system where the spaces of providing healthcare aren’t necessarily just hospitals, but also homes and communities.

Personally, the problems come from doing anything entrepreneurial. So much of our culture around entrepreneurship is like “hero-preneurship.” We glorify individuals and assume a linear path. There’s an article that talks about the psychological price of entrepreneurship. In my experience, I’ve found that if we share our vulnerabilities with the people we trust, we actually turn out to be stronger and can build on our common strengths.

DP: You mentioned facing practical and philosophical barriers. Did you face any cultural barriers in bringing modern healthcare to communities that had, perhaps, not been previously exposed to it?

RP: There often are cultural challenges in the work we do. For example, I spoke to the students here about a woman named Ruth Tarr. We hired Ruth when she was 23 and had gone about a dozen years without schooling and without a job in the formal economy. Ruth lives in a rural village in the rainforest of Liberia in a county called Rivercess. These are the very places with the lowest rates of vaccination coverage or the highest rates of maternal and child mortality. These are the challenges we can prevent if we hire, train, and equip people like Ruth and make them part of the medical team. People like Ruth are from the rural communities you spoke about and they have a deep cultural context. For us, engaging and being sensitive to these cultural barriers is a critical part of our work. The clinic-based delivery rates have improved in Liberia due to the national program that has brought thousands of workers like Ruth into the healthcare system. If we invest in the people closest to the problem we want to solve, we’re much more likely to be successful.

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DP: What does the path forward look like for you, and what are you most excited for?

RP: I’ve seen this idea of investing in more proximal community-based primary healthcare systems be implemented in different communities around the world and how powerful it can be. I first learnt about community health workers in Alaska’s fishing villages. Health workers like them make it possible for us to achieve that vision of bringing modern primary healthcare within reach of everyone, everywhere. The data generated from this global movement is tremendous. We know that if a global army of community and frontline workers was deployed in rural communities that lack coverage today, which half the global population does, collectively these workers could save an additional 30 million lives by 2030 if we started today.

Often, the challenges have to do with building these systems of community health workers. The questions of how do you advocate for, how do you build coalitions, and how do you optimize systems is the focus of our first leadership course on the Community Health Academy platform, which is being jointly produced by Harvard and edX and taught by a network of faculty from around the world. We sent film crews to Bangladesh, Ethiopia, and Liberia so health systems leaders can learn from other health systems leaders. Enrollment for the course began earlier this month, and already, people from over 90 countries have signed up.

I think that’s very exciting because this means that people want to learn how to do this work better, and they want to learn from their peers.

DP: For students who are interested in making a difference but don’t know where to start, what advice would you give in terms of identifying a problem and designing a solution?

RP: I have three pieces of advice. First, find what you’re passionate about and what really energizes you, not just your mind, but also your heart, your hands, and your soul. Second, match your passion to the urgent needs of the world. You don’t have to be a physician or a public health major to work in global health. My third piece of advice is to stay in it for the long term. This relates back to the first two pieces of advice because to stay in something for the long term, you really have to like it. This could be a long-term commitment to a place, Liberia in my case, or a long-term commitment to a cause, like extending rural healthcare. A paper published in the Harvard Business Review found that the common link between audacious social movements, like polio eradication, was long-term engagement, measured not in years, but in decades. Breakthroughs take decades, not years. 90 percent of those movements required two or more decades of engagement. As students, you have time on your side. So, if you can find something that keeps you passionate and stay close to the problem, you will be more likely to succeed.