Nadia Miniclier Cobb, a faculty member at the University of Utah PA Program, was interested in global health issues long before she began her career. Now as the director for the Office of Global Health Care Equity — a position that was created less than a year ago — she is working with the World Health Organization to recognize PAs and their counterparts throughout the global health care workforce.
Transcript of Nadia Miniclier Cobb interview
Nadia Cobb: A couple of years ago now, I was contacted by the World Health Organization after the World Health Assembly in 2013. A request came from that meeting, asking for the development of a global evaluation toolkit that would evaluate a health workforce education. The uniqueness of this toolkit is not just to evaluate what the current situation is in countries, but to actually be able to help them transform as they move forward. A snapshot of now and a transformation, hopefully, for their future.
I was asked to be a part of this working group, and I was terribly intimated at first because it’s an incredible group of leaders and visionaries and people who have spent their careers, changing global health and health policy. Just absolutely inspiring.
I started working on this. From that has evolved numerous other opportunities, conversations, partnerships, and collaborations — one of them being the Transformative Education for Healthcare Professionals website, through the World Health Organization.
I’ve been asked to be a blogger on it as well as to develop and bring forward case studies and both co‑authorship as well as editorial roles to really show the global workforce that exists. Workers that are similar or analogous to the physician assistant in the U.S. The problem is, however, in global policy levels that the International Labour Organization does not have a category or a definition for us. If you look in their definitions, you’ll find us, meaning the global PA workforce, spread out in technical areas and paramedical areas. We’re spread from here to there.
Rather than research being done and literature reviews, we actually have folks actively co‑author or author themselves. It is really based from the country representative. From that has grown an article and a research article which will be coming in the fall in the World Health and Population journal, which was commissioned for us to really try to explore this workforce globally.
The team that we developed for this research went forward to try to define that PA analog workforce. As we were doing this and as I was talking to folks at the World Health Organization and other organizations that I’ve since become engaged with, phrases started popping up. A discussion was had as far as that we need to figure out a name that’s going to be descriptive, that defines our category of health worker. Through numerous, very casual organic conversations, the accelerated medically trained clinician came forth.
It seemed to be something that really resonated amongst folks at the policy levels, funding levels and basically, it is a clear definition saying that we are trained under a medical model. We’re regionally specific. We are clinicians.
We’re trained in an accelerated way, that’s most often, regionally specific, we are cost‑effective. We have risen within our own countries and own regions, often in parallel to other nations. We are culturally and historically accepted within those regions. We also carry out our names within the regions that really define who we are. I think to me, it’s vital that remains. The title of “accelerated medically trained clinician” is not something that clinicians will introduce themselves as when they meet a patient. It is in no way, shape, or form meant to be that. What it is, is a category.
I know the PA profession in the U.S. is extraordinary and has really grown and now over 100,000 strong. There are people that we don’t really know about maybe who were further ahead than us in this model. The Felchers in Russia in the 1600s. Mongolia has had something very similar for many, many years that is a primary care accelerated medically trained clinician type workforce, that travels actually with the nomadic tribes there to provide primary care. Kenya has had their clinicians since 1928, clinical officers. There’s over 15,000 of them registered through the Clinical Officers Council.
I think that as you start to think of the global impact of this workforce, it’s really exciting. They exist in Asia, Africa, Australia, Oceania, Europe, everywhere. The study actually concluded that we found them in over 48 nations.
I think one of the vital parts of having the accelerated medically clinician actually, officially recognized globally will be to increase accessibility of health care. The hope is that this workforce will be able to expand through this recognition, will be able to continue the regionally specific work that they do.
The hope is potentially that regional models will be developed that other countries that are interested, that have seen models at work, can reach out to places within their own regions rather than having a colonial approach and saying, “Well, we have this and, therefore, everybody else should have this.” I don’t agree with that.
I think there are competencies that we are going to need to explore as a profession, meaning the accelerated medically trained profession, which includes physician assistants, associate clinicians, medics, health assistants, the list goes on for about as deep as 48 nations. As we build competencies in education, and those can go across the board, I think that the competencies will be something that maybe are broader breaststrokes and maybe a little different than what we think of as traditional competencies.
I see social determinants of health being a huge aspect in this. I see world primary care, marginalized populations being a very important strategic aspect.
Interviewer: Have you always been interested in global healthcare or is this something new for you?
Nadia: The travel bug health care global aspect was inculcated in me very, very early without me knowing it. My father was a journalist for the Associated Press. We lived in Kenya. We lived in Egypt. Our home was always full of people from all over the world. I grew up knowing no difference.
As I went to PA School at the University of Utah, I was so drawn to the mission of primary care and underserved populations. As I became a faculty here in 2005, the opportunity arose to explore the potential of having physician assistant students do a rotation in Ghana, West Africa, where our University School of Medicine and other entities within the health sciences had been involved for many years.
I was given the opportunity to go to Ghana by our director at the time, Don Pedersen, and explore this. I was brand new to all of this — my very first visit. Dr. Hale the global head of the School of Medicine, and our group went.
There was actually a summit led by the Administrative Health Department at the time, which was struggling with Ghana’s horrible brain drain. Two out of every three physicians were leaving the country after receiving training in Ghana. At one time, there were more physicians in New York City than there were in the actual Country of Ghana. Ghana has over 25 million people.
We met with the folks from the Ministry of Health. At the same moment, we met Dr. Emmanuel Adjase who, to our great surprise, was the director of the Physician Assistant Program in Ghana. Our partners in the U.S. from the School of Medicine did not know that one existed. Dr. Hale and I were both just, “Oh my gosh, the planets have aligned.” The focus of the Ministry of Health at that time was “We need to scale up and bring forward this workforce.” At that time, they were called medical assistants in Ghana.
Their workforce has existed since 1969. They are the absolute forefront of primary care in the country. They take care of over 75 percent of the primary care needs in the country. They are in the rural populations. They are in the underserved inner city populations. They are the absolute backbone of healthcare.
A few short months after the meeting, we had a delegation that included the now provost from the University who was, at the time, the dean of the medical school that the University of Utah had partnered with for so long, and Dr. Adjase the head of the, at that time, Kintampo Rural Health Training School, and folks from the Ministry of Health. The deputy minister of health herself came and they spent a week here.
Their interests were in seeing rural and underserved PAs in action. They were interested in sharing co‑curricular ideas and seeing how they could change training, make their training more streamlined, and that started a beautiful collaboration that has been ongoing now for nine years.
Just a quick story. That very first trip, they said we want to see rural PAs. So we rented a minivan, and I took them on a 1,200‑mile road trip down to rural Utah, New Mexico, and Arizona. They saw PAs in action on the Navajo Reservation. They saw them in Arizona. It was the best thing to happen because there we were looking at these phenomenally beautiful areas in our rural parts of the country. For them, it was incredibly impactful because they realized that we struggle with very similar issues. Look at the Navajo Reservation and you see their lack of electricity, their lack of access to health care, their lack of water, and it’s no different in Ghana. Those moments really have built us into a partnership that is strong and enduring of equal vision.
Interviewer: What would you say we could learn about health care from developing countries and what they do?
Nadia: I’ll take it from the student comments I’ve received over the years. I think that when students have gone to Ghana, we debrief every night and that can range from very deep, very hard discussions about the infants that they saw die that day to maternal mortality. To, “Oh my gosh, I’m really struggling with the bathroom facilities.” The range is broad.
Consistently, what students reflect upon is their increased awareness of the critical nature of a history, the critical nature of the physical exam and being able to rely on those things as building your differential, as determining your treatment plan. They all say, “Oh my gosh, I didn’t realize how reliant I am on labs, on extra tests to really help me define what I think is going on and to protect myself.”
I think that, for me, one of the aspects that I hope someday we can get back to is really the art of medicine and not relying on doing defensive medicine, because the zebras are zebras. There’s a lot more horses out of there. Part of health care costs and issues are because we’re so worried about zebras.
The other thing I think we could learn from, and really need to learn from, is I think many of our partners — this doesn’t just go for the accelerated medically trained clinician, it goes for health care in general —in their training are really focused and are putting a strong emphasis on social determinants of health, community‑based care, health care starting actually in the community with a small‑based team that then tiers into different layers where health professionals are used to their utmost capacity.
That PA who sits in their rural community clinic, their catchment area is usually 20,000 people. They’re responsible for the disease tracking, understanding surveillance, understanding the vaccination processes, keeping them up to date, having outreach programs that during the rainy season can reach these people in some of these far outreaches of the catchment area. Having a structure that really understands the population needs. The barriers to access issues. I hear these topics, and they’re being discussed with passion and excitement. Often, I’m not hearing the realization this has existed in so many places in the world out of dire necessity.
Really, we don’t need to reinvent the wheel. We just need to learn from each other and be okay with that — really maximize population care from a community level with teams and, obviously, the accelerated medically trained clinician being a part of those teams.
Transcription by CastingWords