AMA News Wire
For this Tulane doctor, advancing health equity has global focus
May 16, 2023
As a medical resident in Louisiana, Anjali Niyogi, MD, MPH, never thought she’d be racing through the flooded streets of New Orleans in a commandeered ambulance, searching for medical supplies to set up ad hoc clinics.
It was 2005, and Hurricane Katrina had devastated the city, knocking down communication and transportation channels, and disrupting an entire health care system.
One police officer she encountered said he had HIV and was running out of his medication. She thought about the demographics of her community, the high rates of type 2 diabetes and hypertension. She wondered how many other people were running low on insulin and other medications.
Dr. Niyogi set up at least six makeshift clinics around the city, offering care to first responders, Latino immigrants who came in to clean up and rebuild, and anyone else who needed chronic or urgent care.
“We set the clinics up adjacent to police stations or first-responder staging areas,” staffing them with volunteers and donations from an emergency care center in Baton Rouge, she said.
“I had gotten keys to a whole warehouse of medications. We would fill people's medications and do urgent-care stuff on the streets adjacent to the police stations. We also discovered people who hadn't left their homes and started to do home visits.”
Her team did a lot of wound care and suturing, setting up IVs and rehydrating people. They hooked up generators to preserve people’s insulin.
She doesn’t know exactly how many people she helped, “but there were hundreds.”
Dr. Niyogi has worn many hats as a humanitarian, patient advocate and global health activist. She spent part of her career in India, where she was born, and West Africa, creating programs to modernize health care in underdeveloped communities.
“I’ve sort of stumbled into all of these things,” said Dr. Niyogi, now an associate professor of internal medicine and pediatrics at Tulane University School of Medicine. The Medical Justice in Advocacy Fellowship, an education initiative from the AMA and the Satcher Health Leadership Institute at the Morehouse School of Medicine, was also a chance finding, but a fortuitous one.
In an exclusive interview, Dr. Niyogi explained how the AMA fellowship aligns with her goals to empower communities and improve health.
AMA: Let’s talk about your work in global health. What have been some of the high points?
Dr. Niyogi: I worked in Ghana in West Africa on and off for about three years. We were working with midlevel providers who had one to six months’ worth of training at district and subdistrict hospitals.
We created an emergency medical stabilization protocol, teaching the providers how to stabilize someone who had a seizure or a fracture so they could transport the patient to one of the bigger city hospitals.
This one 16-year-old girl came in and she was seizing, and I don’t know what would’ve happened before, but they were able to get her to stop seizing. I think the providers felt empowered that they could help their community members. For me, this wasn’t a high-tech fancy intervention.
Organization took some time, but the solutions were quite simple. I really enjoyed that.
In India, I worked in the Himalayas on and off for several years in a very rural subsistence farming community, doing work around pediatrics and pediatric malnutrition. One of the highlights was working with community health workers to conceive, design, write and implement their own grant. They got grant funding for five years, which was amazing.
One case that stands out for me was an 18-month-old girl who had severe developmental delay and malnutrition. For the first time, I really thought about how geography affects health inequities. In the Himalayas in South Asia, girls are already at risk for poorer outcomes than their male counterparts. Had she not lived there, her care and her development would have been very different.
AMA: You launched the Resident Initiative in Global Health at Tulane. Can you talk about some of its accomplishments?
Dr. Niyogi: There weren’t a lot of people doing global health, at least not at my institution at the time. I really struggled with having a mentor. No one at my institution knew how to guide me.
When I became an attending physician and started to realize that more and more people were doing global health and didn’t have mentorship and were also kind of thrown into those same situations, that’s when we developed this Resident Initiative in Global Health at Tulane.
It’s a program to mentor post-graduate residents who are interested in global health, to talk about the ethics of global health, and how to do global health. How do we negotiate North-South power dynamics?
How do we look at an equitable share of both resources? Who is doing research?
In the nine years we’ve been in operation, about 27 residents have gone through our program. They’ve gone all over the world from East and West Africa, to India, to South America, to the Caribbean, doing clinical work, programmatic work, public health work, research.
Some of them have gone on to work for the Centers for Disease Control and Prevention’s Epidemiologic Intelligence Service.
AMA: You started with this cohort of the Medical Justice in Advocacy Fellowship last fall. What have been the highlights so far?
Dr. Niyogi: The cohort of people that we work with in the leadership has just been fantastic. It’s been amazing to be with a group of people who are all aligned similarly with what we’re trying to achieve. Everyone’s thinking about health not from “writing a prescription and you’re done,” but really from that sort of bird’s-eye view of “what are the ways that we can really push for substantial change that’s going to affect all our communities?”
AMA: You attended the AMA National Advocacy Conference in Washington this year. What did you take away from that experience?
Dr. Niyogi: It was nice to see how medical societies as a whole advocate for issues and think about how to better utilize those voices en masse; to look at the ways we can have conversations about topics that are important to us, but then bring them into the larger voice of a medical society, and then hopefully into legislation.
AMA: Let’s talk about another project you’ve been involved with. That is the Formerly Incarcerated Transitions (FIT) Clinic, which you founded in 2015. What are some of the challenges there?
Dr. Niyogi: The incarcerated population is sicker than the general population. They have two to three times increased risk of diabetes, hypertension, and heart disease and five to 10 times increased risk of infectious diseases like COVID, HIV and hepatitis C, as well as mental health illnesses and substance use. When they’re coming back home, they’re coming back as a sicker population.
The greatest challenge of caring for these patients isn’t medical. Because of Medicaid expansion in Louisiana, we have a robust Medicaid pre-release enrollment. People are getting enrolled into Medicaid before getting out of state prison.
The challenges now are the collateral consequences of incarceration: employment, housing, how to reunify with families, and all the bureaucratic and political restrictions that people with felony convictions have, such as voting rights. I always say as a physician, some of the easiest work is just to take care of the medical needs of our patients, but it’s really the complexities of their lives that create more barriers for successful health outcomes.
With the FIT Clinic, we work with two community health workers, both with lived experiences of incarceration. One person spent 26 years at a federal prison, and the other spent 43 years at Angola and Louisiana. They are the experts in understanding the trauma of pre-, during and post-incarceration, recognizing what the needs of this community are, and networking to make sure that we can assist people the best that we can. Housing is probably our biggest challenge. There’s just not enough affordable or transitional housing for people.
When people have been incarcerated 20, 30, 40 years, it’s hard to maintain those community connections. They don’t always have family that they can rely on for permanent or sustained housing.
Through the FIT Clinic we also started the Formerly Incarcerated Peer Support Group, creating the first— as far as I know—curriculum designed by formerly incarcerated people to deal with reentry.
Some of the peer-support groups might say, "Well, you need to go and get a job, or you need to go and find a place to live," which may help you get employment. But some of the things that people, particularly with prolonged incarceration, have asked us is: “We can get a job, but how do you keep a job? How do you deal with authority?" You've been in this institution for so long that you've really learned to distrust authority. When you come back in, how do you then navigate that? How do you leave an institution and come back into society?
A recent session, for example, was on rebuilding parenting and family relationships. This was led by the formerly incarcerated, who had conversations with people who were formerly incarcerated with varying degrees of successful reentry. They can really learn from one another. That's how we're addressing the emotional and psychological impacts of long-term incarceration.
