“Historical oppression. Bitter poverty. Ongoing racism and economic paralysis.” Ask Dr. Sonya Shin about the common threads between her many clinical field sites, and she’ll recite a list of societal ills that, to the uninitiated, may appear to lie beyond the scope of practice of a physician. But as someone who’s spent over a decade caring for underserved populations, Shin is no stranger to the profound way in which a person’s environment can shape his or her health for better or worse. Since as early as 1991, Shin has been identifying, evaluating and overcoming the unique obstacles that face an impoverished community in need of improved access to health care.
Shin’s interest in health equity began when she was an undergraduate student at Yale University. While serving as a volunteer research assistant at the Native American Women’s Health Education Resource Center on the Yankton Sioux Reservation in South Dakota, she conducted a study of diabetes in the Native American population.
“It was the first thing that really resonated with me. Talk about health disparities—there was a glaring difference between the health of the reservation and that of the surrounding communities. The reality of it was that these people’s treatment outcomes were largely determined by factors beyond their control.”
Shin entered Harvard Medical School in 1993 and, after taking one of Paul Farmer’s classes on health and social justice, began to work as a research assistant for Partners In Health (PIH). A mere three years later, she became one of the first leaders of a community-based project to deliver world-class care to some of the sickest and poorest tuberculosis patients in the world. Volunteering as a consulting clinician, Shin moved to Lima, Peru to oversee the initiation and expansion of PIH’s multidrug-resistant tuberculosis (MDR-TB) treatment program in one of the city’s urban squatter settlements. In collaboration with the Peruvian Ministry of Health, Shin and her colleagues identified and sought to treat several thousand patients with MDR-TB.
“I served as the primary clinician during the first year of the project.” But at that time, treating this difficult illness outside of a hospital setting, let alone in a developing country, had been deemed impossible. MDR-TB therapy requires strict adherence to one’s drug regimen, as missed doses often result in an increase in drug resistance. Furthermore, many patients in the developing world lack the resources not only to pay for treatment but also to obtain transportation to and from the prescribing clinic.
To overcome these obstacles, PIH hired community health workers to visit each patient at home on a daily basis to ensure that every dose was taken as prescribed. Known as Directly Observed Therapy, or DOT, this novel approach allowed the program to provide treatment to over 2,000 patients with MDR-TB. The cure rates were astounding: over 80% of the patients were cured, a success rate equal to or better than that attained in major medical centers across the United States.
Today, countries around the world use the MDR-TB treatment approach pioneered by Dr. Shin and her colleagues, thanks in part to the publication in 2003 of The PIH Guide to the Medical Management of Multidrug-Resistant Tuberculosis. Now, Dr. Shin and her colleagues are tackling new problems.
At the request of the Peruvian Ministry of Health, “we’ve started a program to help combat HIV in Peru, which has become a huge problem. We’ve also started a child nutrition program, in which community health workers make home visits to ensure that children are getting adequate nutrition in a way that’s very similar to DOT.” Shin also conducts clinical research that is focused on determining the best and most cost-effective way to conduct screenings for MDR-TB.
Many of Dr. Shin’s efforts now involve sharing and disseminating the broad base of knowledge that PIH has gained through its work in poor settings. Her international work, for example, has broadened to include Partners In Health’s sites in Russia and Haiti.
“In Russia, most of what we do is teaching. We conduct formal training programs in order to teach Russian physicians how to care for patients with MDR-TB. We’re also conducting research on the extent to which the abuse of alcohol is a risk factor for contracting TB. In Haiti, on the other hand, our work is very much focused on patient care—although training the community health workers is always a large component.” Shin is also involved in a major expansion of PIH’s HIV/AIDS treatment program in rural Haiti, an initiative funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Over time, Dr. Shin’s role has expanded at home as well. After graduating from Harvard in 1998, Shin completed her residency training in Internal Medicine at Brigham and Women’s Hospital. In 2001, she began an Infectious Disease Fellowship at Brigham and Women’s Hospital and Massachusetts General Hospital, and then completed a Masters in Public Health from the Harvard School of Public Health. She began her dual appointment as an Associate Physician at the Division of Social Medicine and Health Inequalities and the Division of Infectious Diseases at Brigham and Women’s Hospital in 2003, and is now an Assistant Professor at Harvard Medical School. She also acts as a mentor for medical students and as a clinical consultant for PACT, an affiliate of PIH and BWH that focuses on disadvantaged HIV patients in the Boston area.
“I’m lucky because I have a very supportive family,” notes Shin, when asked about the difficulty of juggling such a variety of roles. “You tend to be overstretched.” And while the success she’s achieved so early in her career is quite impressive, “the rewarding things are really the communities that I work with.”
“I was in Peru in May, visiting the HIV clinic. Before PIH’s arrival, it was struggling to hire staff, and patients would have to spend all day waiting for treatment. The lack of resources had made following up with patients nearly impossible, and the staff was overwhelmed. As we began to provide them with the support they needed, I was struck by the response of so many healthcare professionals who wanted to become involved. Each day someone new joined the team. I was moved by the willingness of everyone to work together so that more patients could be treated.
“Collaborating with other groups, you come to realize that what we’re doing is unique. It’s amazing to see how many people respond, when we look to fill certain positions. The Division has grown tremendously in the time that I’ve been here, and we’re in a great position to find the people who also share this vision. The way that things have been going, we’ve been able to really strengthen the global health infrastructure. We’re building a community, and it’s very gratifying.”
---Rachel Knott
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