In the last month, Lucia Li has been in jail, visited a tattoo parlor and interacted with Child Protective Services. That’s not the typical experience of a high-performing medical student.
Li wanted to get outside of the clinic and into the community — ground zero for America’s healthcare challenges. She seized a new opportunity to participate in the Public Health Externship at the Indiana University School of Medicine. It’s a four-week immersive experience walking alongside public health workers at county health departments throughout Indiana.
Li was assigned to Vigo County, based in Terre Haute, where Joni Wise has been the health department’s administrator for the last 30 years.
“When a student is here, it really helps us explain our work to others and kind of reignites why we love what we do,” Wise said. “No day is ever the same in public health. You just play it as it lays — whatever’s in front of you.”
That could mean collecting a dead bird and sending it to the state laboratory to test for the spread of avian flu or collecting discarded tires from rural areas to prevent mosquito breeding. Another day could be spent in the county jail conducting tests for sexually transmitted diseases or running health education programs. Some days will bring regulatory inspections of restaurant kitchens, public pools or tattoo parlors to prevent the spread of disease-causing germs through poor sanitation practices.
On a recent day, Li was along for the ride when the health department was notified a local family had awakened to the screams of their children — a bat was in their bed. The department’s vector control division captured the bat and sent it for rabies testing while affected family members were started on a series of post-exposure prophylaxis vaccines. When the department realized this family was also one of their lead exposure cases and had fallen behind in checkups, they coordinated within divisions to ensure the family received vaccines and lead follow-up together.
“It is an insane variety of things they do,” said Li. “I conceptually kind of understood certain functions of what public health workers do, but now I’m actually seeing how many departments they have and how they all work in parallel and partner with the clinic to make sure specific cases are kept up with. They have the septic team, social services, environmental services, vector control — it’s a lot of things they do and do really well.”
Intervening upstream
When public health works well, it’s invisible. Problems are prevented before they develop into a community crisis.
“If we don’t provide good preventive health and health maintenance, then we’re left dealing with the consequences,” explained Bradley Allen, MD, PhD, senior associate dean for medical student education at the IU School of Medicine.
His team designed the Public Health Externship to be an immersive “boots on the ground” experience that would stick with Indiana’s future doctors. As medical professionals, they should not only treat the patient in front of them but also think about the factors which brought the patient there — and how they can advocate for upstream interventions.
Funding for the externship came from a $15.4 million grant from the Health Resources and Services Administration. The grant helps fund the Indiana Primary Care Advancement in Clinical Training program (INPACT), which is designed to recruit more medical students from medically underserved areas of the state and to provide Indiana doctors with the tools they need to offer high-quality primary care to vulnerable communities.
IU School of Medicine has also enhanced its curriculum by adding studies in health system science and social determinants of health — environmental factors including where people are born, live, grow, work and age, which significantly affect their health and well-being.
“We continue to increase the presence of health system science content in all phases of our curriculum, which exposes students to better understand complex health systems, provide patient-centered care, enhance clinical outcomes, and develop skills to improve patient experiences by understanding social determinants of health,” Allen said.
In addition to the Public Health Externship, IU medical students may participate in public health opportunities through scholarly concentration programs or even add a master’s in public health to their MD in partnership with the IU Fairbanks School of Public Health.
Li and several other IU School of Medicine students attended Public Health Day at the Indiana Statehouse on Feb. 12 to learn more about advocacy through public policy. She sat in on a board meeting for the Indiana Public Health Association where members discussed proposed bills on topics including the state’s Syringe Exchange Program, food truck regulations, healthcare affordability and disparities in maternal and infant health.
“I want to stay involved in public health and public policy,” said Li, who plans to specialize in psychiatry. “Being in the role of a physician, I think you have a unique relationship with public health.”
Bridging the gap in healthcare
While Li shadowed health officials in Vigo County, another Indianapolis medical student, Ishan Sran, completed the externship with the Clark County Health Department in Southern Indiana, near Louisville.
Sran became interested in public health after taking an LGBTQ healthcare elective and realizing how important pre-exposure prophylactic drugs were for preventing the spread of HIV. During his time in Clark County, Sran worked on a research project examining public attitudes toward the HPV vaccination. He learned that Indiana has a 55.2% rate of HPV series completion among adolescents — lagging behind the national average of 61.7%. In Clark County, the adult coverage rate is just 38%.
This matters because HPV, a common sexually transmitted virus, causes up to 99% of cervical cancers along with some oral and other types of cancers. Indiana ranks fifth nationally for its rapidly increasing rate of oropharyngeal cancer.
Sran conducted a small survey which indicated more education is needed in the community. He proposed that the county advertise HPV vaccination in the same way it does for annual flu shots.
Hosting medical students like Sran for an immersive experience at the health department helps them gain understanding of the impact public health can have at the macro level, said Clark County Health Officer Eric Yazel.
“I think as we provide early exposure to public health, especially outside of traditional rotation sites, this will allow our students a better understanding of the underlying public health issues present in the communities they will serve and motivate them to get involved, not just at the individual patient level, but the systems level to address these barriers” Yazel said.
As a future pathologist, Sran plans to “be a good advocate” by participating in disease surveillance and reporting trends to appropriate agencies in real time.
For Li, a future psychiatrist, interacting with inmates at the county jail was particularly impactful. Through group therapy sessions designed to increase moral reasoning and improve decision-making, Li saw the circumstances that can lead to incarceration and how public health can intervene to help break that cycle.
Her research project examined lead poisoning and prevention strategies. Exposure can come from chipping lead paint, contaminated water or soil, and other sources. Vigo County has a dedicated lead case manager with more than 80 open cases. Li discovered this role isn’t standard for all counties; she proposed better training and a dedicated lead case manager for every Indiana county.
“Lead poisoning is preventable,” Li said. “And we do see persistent disparities, particularly in Black and Hispanic children and families. Families of lower socioeconomic status are also at higher risk.”
Li is the second IU medical student to complete the externship with Vigo County, but several other students have shadowed over the years. Wise welcomes this ongoing partnership.
Regardless of the medical specialties these students go into, she’s confident these future physicians “will always be friends of public health.”
