The Bulletin is the student newsletter of the Graduate School of Arts and Sciences. Printed eight times during the academic year, and updated continually online, the Bulletin profiles PhD and master's students and reports on GSAS news and events.

An MD/PhD student works to mobilize local communities to improve health care in Africa

Scott Lee with his bicycle in front of an ivy covered building.

To the endeavor of improving health care in the world’s poorest regions, Scott Lee brings two conspicuous assets. The more obvious is the $100,000 grant that the MD/ PhD student in Harvard’s Health Policy program won last April from Massachusetts General Hospital, for research into community health in rural Africa and India. Money alone, though, is not as impressive as it once was in global development. Easy enthusiasm about the transformative power of Western largesse is increasingly running up against a recognition of the complexity of intercultural cooperation, and a growing chorus of critics is challenging core assumptions of international philanthropy. In this atmosphere, Lee’s second asset may be the more significant: when he began his global development career ten years ago, it was not with enthusiasm, but with a sense of despair.

At the time, Lee was a Harvard College junior who had just returned from his first trip to Africa. During sophomore year, he had discovered an interest in global health and begun working with Partners in Health, the nonprofit co-founded by Paul Farmer, MD/PhD ’90, Kolokotrones University Professor. Encouraged by Farmer to get field experience, Lee traveled to Ugunja, a village in western Kenya, during what happened to be the nadir of the country’s HIV crisis. He had hoped to discover a way to make a difference, but instead spent most of his time by the bedsides of the dying.

“I came back for junior year traumatized by what I had seen,” Lee remembers. “Suffering there was so ubiquitous that it seemed utterly mundane. I couldn’t reconcile that with the notion I had developed that unnecessary suffering is a moral travesty, something we can and should eradicate. Going into that summer, I felt a ton of agency. Coming out, I felt helpless and hopeless.” He even wondered whether basic concepts like justice and suffering weren’t merely Western constructs. “What if for them, when someone died at thirty, that was just a routine matter — premature only by our Western standards of longevity?”

He decided to ask just that question. He designed a senior thesis on how AIDS sufferers in western Kenya made sense of their illness, and returned to Ugunja to interview villagers about whether they found it unjust that treatment for their illness was scientifically available but not within financial reach. “And the answer I got, time after time, was that, ‘Yes, this is unjust, yes, the world shouldn’t be this way, and yes, we can change it. You should change it.’ It restored my senses of both responsibility and agency.” Since then, Lee has returned to Ugunja every summer, working with villagers to establish two schools, a microfinance program, an agricultural training program, a computer training center, and a health clinic. Along the way, he co-founded a nonprofit, earned master’s degrees from Cambridge and Princeton, and spent time working for the World Health Organization.

For Lee, what made the difference between despair and determination was an understanding of the power of local communities to create positive change. “I learned very early on the futility of fashioning myself as a hero trying to save the world by myself. The only tenable path is partnership, and the best way that I can contribute toward a better world is by empowering others in their efforts toward the same.”

He remembered this when it came time to plan a dissertation. He began speaking with a friend from college who worked for Dimagi, a Cambridge-based company that develops innovative health care solutions, including mobile phone software for community health workers (CHWs) — locals trained to provide basic primary care in areas where access to doctors is scarce. The recent availability of cheap cell phones has effected something of a renaissance in community health, by allowing workers to quickly access, record, and transmit information about their patients. Lee appreciated the value of this technology, but also recognized that its full potential lay in its interplay with underlying social factors, such as what motivates health workers to serve their communities. Together with the company’s directors, he began thinking of ways to make the software socially meaningful. “What I really like about Dimagi is that even though they believe in technology, they recognize that it’s not a panacea, that there’s a need for a human component behind all of this.”

The research for which Lee and Dimagi won the MGH grant is specifically designed to study the importance of performance feedback. “In most community health worker programs, CHWs fill out reports, submit them, and never hear back. Have they done a good job? How does their performance compare to other workers?” Without this information, Lee contends, the entire task of health work becomes demotivated. By providing workers with a phone-based “dashboard” containing automatic, dynamic charts and graphics depicting their performance, he hopes to enable health workers to track their impact and progress over time.

For Lee, this work is as much about the developed world as the developing. “Our primary care system in the US is even more broken in terms of the misalignment of incentives, our lack of tools — beyond drugs — to help our patients, our pattern of seeing patients once a year and doing nothing for them in between,” he says. So the question Lee’s work addresses is a universal one: “How to mobilize and motivate communities to take health into their own hands.” Whether you are an African villager who knows you should treat your water with chlorine solution, or an American office worker who knows you should eat more nutritious food, Lee says, “We know what we need to do, but it’s hard to do it. Being the healthiest version of ourselves is harder than climbing Mount Everest. We all need support to climb that mountain.”

The Power to Change