Infection and Inequality - an interview with Wadham alumna and Rhodes Scholar, Julie Levison

I'm a community-based infectious diseases physician and health equity researcher based in Boston. It’s an exciting place to practice medicine!

The heart of my work sits in Chelsea, a densely populated city right near the airport of Boston. Chelsea had a dramatic experience with COVID-19 and was one of the early epicentres of COVID-19 in the USA. Chelsea is a city that represents both resilience and socioeconomic deprivation.

I’m based there as a clinician providing infectious diseases care, but also as a public health leader, trying to imagine how we can make services more accessible and responsive to patients.

Many health services are delivered within a hospital setting. But that only goes so far because people need to be able to access and use those services. For example, the city I work in is seven miles from Boston, and those seven miles require crossing a large bridge. Crossing it requires money for transportation and logistical time taken from your day. That’s not easy, especially when you work multiple jobs in a day. So we are a health centre embedded within the community itself.

Beyond the geography, being a community-based physician is also a psychological orientation. It involves thinking about how people access healthcare, their culture, and their life experiences. To that end, I collaborate with community organisations, health care systems, patients and government to bring everyone together to think about healthcare. And in my own research, I shy away from the traditional academic lens, which tends to be hierarchical. The ‘community-based, participatory’ model I work with assumes that everyone coming to the table has something valuable to share, whether the patient, physician or wider health care system.

What makes the practice of medicine an art is that you take what you've learned in a textbook and tailor it to a real-world setting. The patient offers the opportunity to really think: “how am I going to care for this person in a way that's going to be effective?”.

I'll give you an example with COVID-19. We had to make sure people had access to rapid testing and that community members knew about COVID-19 vaccinations, including booster shots. But how were we going to do that when competition for time and attention challenge people’s capacity to prioritize disease prevention? It turned out that the food pantry line was a really successful way to deliver COVID information. So while hundreds of people were waiting in line to get their weekly food, we offered them rapid test kits along with face masks, hand sanitizers, and the opportunity to get vaccinated for COVID-19 and influenza.

You can have an aspiration to implement vaccination but to make uptake effective, it is critical to bring prevention where people are and embed it with things that community members need and value.

Yes, and my time at Wadham was foundational to that. Although I knew I wanted to be a physician, I took a non-traditional path and studied history first. I read the MPhil in Economic and Social History at Wadham, with a concentration in social history of medicine. In those early months of the course, I was exposed to a lens around colonialism that I had not thought about critically in my earlier work.

When I returned to Boston and started at Harvard Medical School, I don't think I could have anticipated how much the lens of history would change my practice. History allowed me to think of medicine beyond the patient/physician dyad to acknowledge all of the social, systemic, and cultural factors that produce disease and illness.

The Scholarship puts you in touch with people across different disciplines and that was critical. Both the Scholarship and student life at Wadham gave me the possibility of speaking with colleagues, peers and teachers who helped me holistically address the questions that engaged me. I still remember the conversations with friends from my stairwell in College and living in an international community in our college flat in Merifield in my second year.

My Wadham advisor, Dr. Jörn Leonhard, was a college tutor in modern history, and was a consistent source of guidance outside of my course. During the research and writing of my thesis, a social history of leprosy, Jörn understood why the topic animated me and its significance as a model of stigma and illness. He helped me to identify funding so I could conduct independent archival research, which led me to find old letters written by patients in isolation. Jörn invited his advisees every term to Wadham High Table, which was such a memorable experience.

For me, the interesting questions have been how to deliver effective care to people most marginalized from the health system. That requires a behavioural, psychological and intellectual skill set that's very different than the biomedical approach. That path required me charting a course that was in some ways unconventional. Having the Rhodes Scholarship and having been at Oxford provided me the credentials to take risks down an unconventional path.

Both my parents are retired physicians and I think that early exposure helped me see that medicine was a calling for me. But my parents encouraged me to view my undergraduate years as a time to explore because it would be harder to be that expansive as my training got more specialised.

In addition, from my very earliest years I’ve gravitated towards storytelling. My grandmother migrated to this country from Europe after World War One. Our family was imbued with the immigrant experience and stories from that experience. The process of sharing stories and remembering history was something very alive in our family.

Plus, unless you are the rare person whose life story is published, for the ordinary person, we really don't leave a written record of our lives. The physician note becomes the record. So for me, the encounter with a patient becomes deeply honorific. And when you’re working in a community where people have been historically devalued, giving someone the space to tell their story - why they're showing up to see you - becomes important, meaning clinically valuable as well as humanizing.

Infection and inequalities seem to be forever intertwined. Consider COVID-19. In some ways, it’s a great equaliser. It’s a respiratory borne infection and so we can all be infected because we all breathe and share air. But some people have greater risk of exposure than others, like those who are essential workers for whom quarantine and isolation are a luxury.

In addition, access to healthcare was not equal during the pandemic. During the public health closures of COVID-19, our clinic visits changed to telemedicine. But what does a patient need to receive telemedicine? Obviously, a telephone. But at its best, you need a computer with video access. So there are all sorts of assumptions that are embedded in the capacity to do telemedicine, which creates disparities based on people's resources. To treat and prevent disease, particularly in a sustained way, disease models need to transcend the biomedical sphere and include the psychosocial and the systemic or environmental contexts.

I’ve become very interested in cases where people have access, in theory, to medicines for diseases like HIV, but don’t take those medicines. What are the barriers that prevent people from taking them? To find out more, I did numerous ethnographic interviews with Latino migrants and immigrants with HIV and their health care providers. Some themes emerged. The number one barrier to using their medicine and coming to doctor’s appointments was stigma. For a lot of these patients, no one in their circle knew about their condition. They were afraid of persecution if they were to be found out. They were afraid of being isolated from their family, their friends.

So we took those stories and made a film called Tiempos de Cambio or Times of Change [see below for the trailer of the film.]

The idea is that when a patient comes to an appointment, the community health worker would watch the film with the patient. It’s like two people looking at a painting together and asking, “what do you see?” It can be easier to open up someone’s experience through a piece of art than through asking, for example, “when you were five, what happened to you?”. We have now applied to the National Institutes of Health to do a randomised trial of this intervention to improve health outcomes so that will hopefully be next.

It is so important to be in touch with what inspires you. If that’s care of others, one should heed that inner calling. I also think being curious is central because the hallmark of a good physician is always asking questions and wondering, “what might I be missing? Could I be thinking about this differently?”. Part of that curiosity is also about how we have conversations with one another. You go into a conversation not knowing what you might talk about and what you might learn from someone in the process. Take those opportunities in the dining hall, at high table, and wherever you are. Allow yourself to be curious, surprised, and to change your position on something!

Many thanks to Julie for her time.

Click here for more information about the Wadham-Rhodes Dinner.

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