Breena Taira, MD, MPH, is the Director of Research for the Olive-View UCLA Department of Emergency Medicine. She is the US Director of Project SEMILLA, an organization focused on growing emergency medicine education in Latin America. Dr. Taira is also the Director of IDHEAL, the UCLA Department of Emergency Medicine section of health equity. She was interviewed by Nicole Blum, a third year medical student at University of Illinois at Chicago College of Medicine. Their discussion covered Dr. Taira’s work in health disparities, the origins of Project SEMILLA and IDHEAL, language justice and the trans-national nature of work in health equity.

Edited by Kian Preston-Suni, MD, MPH

How did you become interested in health disparities, specifically language access and health literacy?

I think it was a combination of things. I did a research fellowship at Stony Brook University as part of my training. It was a research fellowship in burn and wound healing, but, as part of that fellowship, one of the things I did was work with a lot of big datasets. One of the things that was really striking to me was—as I was kind of learning how to do these epidemiologic studies—that even when you weren’t looking for them, there were such striking disparities in so many of the different datasets. It really opened my eyes to, on the population level, that there’s really something going on. Seeing [these disparities] in multiple data sources, even though the intention of the fellowship was to study injury, really caught my attention and made me interested in health disparities. That was the initial interest, and then the language interest for me has always been there. At one point when I was a kid, I was really interested in languages and thought maybe I’d be an interpreter when I grew up. [Language access issues] are something that we see clinically a lot, but they’re something that we don’t actually intentionally pay that much attention to. I noticed throughout my training that there were so many language and communication issues with the patient that would hamper good care, but no one was talking about it explicitly and I really wondered why that was. This was something that, in those first days on the floor as a medical student, caught my attention. I tried to watch, over several years of my training, people who navigated language barriers effectively and what they did. Then, I realized as I was going through my fellowship and became junior faculty that no one was really researching what the best practices were. The combination of those two interests was what got me started in doing research on language in the clinical setting.

What inspired you to create Strengthening Emergency Medicine Investing in Learners in Latin America (Project SEMILLA)?

When I was at Stony Brook University, they were looking for global health elective location, and so Stony Brook sent me to Nicaragua initially to figure out if there could be a global health rotation for residents. What ended up happening was that while I was in Nicaragua and made friends with some clinicians there, I heard from them how difficult it was to access new information. One of the first questions that went out to me was, “Can you tell us what’s in the ACLS course because it’s too expensive for us to take.” That was just a really striking comment. The clinicians there had all this curiosity, they wanted to learn, they wanted to know, but it was the financial barrier set up by U.S. institutions that was actually preventing them from obtaining the knowledge. A group of friends, initially all from Stony Brook, got together. This was at the time when the new 2010 guidelines were coming out from the AHA for ACLS, and we said, “Why don’t we go back and do a little seminar for them? We won’t teach the ACLS class because we can’t do that without charging a fee, but we can do a summary seminar for them on the updated guidelines.” [Project SEMILLA] started from that and then kept growing outside of Stony Brook to multiple universities. When I moved to LA, I met many more bilingual providers here that were interested in teaching too. We have worked a lot with the National Autonomous University of Nicaragua, and we have a new partnership with the National Autonomous University of Honduras now. Basically, the idea is that information that can save lives should be available to all, so what we do is create our own courses that are resource and language appropriate for the environment of Central America in conjunction with faculty at the universities there. We provide access to the updated journals and the information, and then [the universities] provide the information as to what actual resources are available in the clinical setting. From this partnership, we build new courses that are based on the same science but are more useful in the clinical setting specific to that region.

What are some of the biggest challenges you have encountered with Project SEMILLA and how did you address them?

In Project SEMILLA—and all global health—world events influence what happens in projects. This is the case in any setting, really, but particularly in places that are less politically stable. We had just done a nationwide trauma symposium in Nicaragua in February 2018, and it was attended by physicians from throughout the country and sponsored by the Ministry of Health. We had big plans to continue in that way. But, in April 2018, political instability in Nicaragua started because citizens were unhappy with some of the changes the president was making with the social security system. This led to massive protests in the streets, so we had to halt a lot of our programmatic activities because suddenly the whole focus of the country changed. It was strangely fortuitous that we had just done this trauma seminar because then there were all these protests in the streets with additional trauma going on unfortunately. We had to change how we were working in Nicaragua to make sure that our partners there did not come under suspicion for being active with U.S. organizations for instance. What we’ve done instead, for the past few times we’ve been in Central America, is have the U.S. group go up to Honduras, and we’ve brought our Nicaraguan leaders up to Honduras to meet us there as we kind of wait out this situation and see. But it’s starting to stabilize. That’s one of the things about global health, you make friends and you have colleagues that you really work with and trust and know well over years, so just being there for them through the more difficult times and saying, “Yes, of course, we’re going to continue afterwards” is helpful as well as finding ways to keep in touch and do some work despite the political changes. Politics in general is challenging. You can imagine the same thing is true here in the U.S. with government changes. One of the things we’ve been documenting here is the increased level of discovery of immigration status in the emergency department. So patients are reluctant to come in for care, and they’re reluctant to sign up for programs. When you look at it, these are bigger political forces that we just don’t have control over. But we can locally at least recognize that that’s happening and try to change our messaging. People need the message that the hospital is a safe place, and the ED is a safe place. This is something we didn’t intend to be involved with initially, but the political situation changes and it impacts what we’re working on here.

What have been the most rewarding parts aspects of Project SEMILLA?

I would say the mentorship of other junior faculty and the fellows. It’s great to see how passionate the current residents and fellows are about health equity—finding creative ways of working towards health equity and changing our health care system for the better. Helping guide that younger group, giving them the academic skills to take on some of these problems and become independent, and seeing that progression happen is really amazing. It’s one of the things that keeps me motivated to keep on working on this, too, because I can see that it’s not just what can I change about things, but the multiplicative effect. When I train others, we can do more things and do more good for our patients overall.

How can people get involved and support Project SEMILLA?

Project SEMILLA is all volunteer based and we welcome volunteers. I would say it’s a very bilingual group so if you’re not Spanish speaking already it might be more difficult to participate. But we’re always looking for people who are bilingual and dedicated to emergency care development to help out with our projects. I think the other thing too is that we’re always looking for volunteers who are interested in education because a lot of what we do is education for providers and fostering leadership in the other country. We have a full team of Project SEMILLA instructors in Nicaragua who teach our courses independently. It’s not beneficial if information can only be spread when someone flies there from the U.S. We want to make sure that we are the conduit to help leaders in Honduras or Nicaragua and other countries to provide high quality educational programming for their own mentees and trainees.

Can you tell me about International and Domestic Health Equity and Leadership (IDHEAL) and what it was like to start it?

Four or so years ago, emergency medicine at UCLA initially got its department status. Historically, emergency medicine was always part of internal medicine; so when they said emergency medicine was going to become its own independent department, what that meant was a few things. Several of the UCLA hospitals were then unified in terms of emergency medicine where it was a much larger faculty—we felt more unified under one department title—and then also we got a new executive chair. In our first faculty meeting with the new executive chair, he said, “Come to me with proposals, I want to know what you want out of this academic department.” There were several of us here at different hospitals that were really interested in both social emergency medicine and then also global health and health disparities. We were wondering how we could all unify to work together better, and we really talked about how we wanted to define this section. We decided [IDHEAL] should be a section of health equity because we wanted to focus on the goal. It’s not that we want to just focus on disparities, we want to focus on how we actually achieve health equity and the links between all of these different areas that are all connected by this theme of health equity. This includes global health projects, border health projects, immigrant health projects, and social emergency medicine. They really are strongly connected to one another, and we felt like, especially in LA, it’s kind of a false dichotomy to say one thing is global health and one thing is social emergency medicine when the population that we see here in LA is either moving in between countries or in between borders—everything is so interconnected. We wanted to emphasize that connection and the overarching goal of health equity for all.

Has working internationally changed your perspective on health care and health disparities in the United States?

I think, sitting here in Los Angeles, it’s a continuum. That’s really my perspective on this. It’s not that some things are global and some things are local. To me, it’s all connected because the vast majority of the patients I see in my own hospital in Los Angeles are from Mexico and Central America, and the vast majority are Spanish speaking only. I feel very connected to the providers in Central America and Mexico because we’re treating the same population. From a population health standpoint, that’s why we really need solidarity—not just from other emergency physicians in the U.S., but throughout Latin America as well. The connection may not be so obvious in other areas in the U.S., but here in LA it just makes everything clear of how health is interconnected across borders.

What can physicians do to promote language justice?

I would say the most important thing is to make it part of the culture and making sure you know it’s accepted to take the time to use the certified health care interpreter. It’s important that, when we’re modeling for residents and when the residents are modeling for medical students, everyone is on the same page. We want to make sure everyone has the opportunity to speak in the language they’re comfortable with and to be understood. Even if someone speaks a little bit of English, but the family members don’t, it’s crucial to create that environment where you say “No, it’s okay we can get the interpreter.” We want to make sure that everyone has the opportunity to understand and ask their questions. There’s this idea that [language justice] is a tradeoff with efficiency so sometimes people feel pushed not to use language services, but we, as a whole, need to make it okay to make that extra time because we know it’s important for patient outcomes.

What are your thoughts on the future of social emergency medicine?

I think it’s going to become even more important and relevant. It is now, but I think it will be more important as people begin to reflect on what’s going on in our health care system and the lack of social support for people living in the U.S. My hope would be that people begin to view the health implications of social determinants as part of health care so that we can make the connection between social service agencies and the health care system even stronger. In the end, it’s the patients and population health that will benefit from it.  

Are there any other projects you are currently working on or hope to start working on?

One of the other major things that we’re working on here is actually implementing universal screening for unmet social needs throughout our entire health system. We talk a lot about screening and how to screen, but when you really drill down in the literature, there’s a lot of research that still needs to done about what’s the best way to screen and who’s the best person to screen and how to strengthen connections when you have a positive screen. There are so many different areas. We’re just in the initial stages where there’s good evidence coming out of some primary care clinics and pediatric clinics, but we need larger and more definitive evidence from emergency departments to support these projects that we’re all involved in. I think there’s a lot of opportunity for people who are interested in those areas because there’s so much work to be done in laying the groundwork to show the impact that addressing social determinants of health in the emergency department can have. 

Is there anything else that you would like to add?

Being involved in health equity and all these different projects adds to how rewarding the work is. You’re not just seeing each patient individually; you’re making an impact in the larger system and population health. For residents and medical students who have interest in these areas, there’s plenty of work to be done, so I would encourage anyone who has interest to get involved.