Behind the Lectern: Malabika Sarker

You got to know that community and you became a part of it. How important is it for providers to understand the communities they serve?

I do think it's very important. It's not only saving a human life, it's also connecting with the person, because when we prescribe a medicine, or we advise a certain lifestyle change, we need to have trust. We need that person to trust the physician, so understanding the community and also the culture, the religion, the context, is very important.

How do you communicate with a person? I'm from Bangladesh, I speak the same language, but when I arrived, I was a stranger because I'm a physician. It automatically creates a hierarchy relationship. To be accepted, I needed to understand their vocabulary, I needed to understand what is important for them. These soft skills are very, very important to be a clinician or to be a researcher.

As a researcher, as a teacher, I do think that understanding the community, whether it's the student community, whether it's the patient community, or women in a village, it’s very important to connect. And the only way we can connect is if we understand them. And if you want to understand them or communicate with them, you need to know their world. 

Tell us about implementation science and how it’s important to your work.

Look at tuberculosis. A tuberculosis-positive patient, when they take the medicine: it cures them. But in Bangladesh, there is a taboo or stigma—if a girl has tuberculosis, it’s very difficult for her to get married. Most girls, they don't seek care; if I just implement a program and say, ‘Okay, come for tuberculosis treatment,’ those girls will not come. So implementing a tuberculosis treatment program in her community could need a different kind of strategy. 

We have to give a different message for those girls, and do something to reduce their stigma.

That’s implementation science: When we implement an intervention, we look at how it should be implemented, what should be the strategy? If you want to have a COVID-19 vaccination program, the way you will implement or send the message out in Rhode Island will be different from what would work best in Mississippi or Alabama. You might not send the same message to the 60+ population as you would to youth. 

Implementation science looks at the implementation strategy and asks: what are the challenges? What are the facilitating factors? And that made me come to this field. I found my heart bridging research and implementation.

How do you think public health needs to change to reflect a more community-based approach? What would be your advice to the larger organizations that control resources? 

The purpose of public health is to generate solutions, to develop interventions and implement interventions for better health outcomes. And if we want to do that, community engagement and understanding is very, very important.

Although we claim that we are global, we are becoming more tribal. We are not open to other solutions or populations.

I was pleasantly surprised when I joined Brown to see the school has a director of community engagement. Because normally academics, you know, we are very arrogant! We do research, we publish, but we are not inherently interested in community engagement. We collect the data, analyze it, write the paper and publish it in a top journal.

But Brown has somebody to encourage integrating the School of Public Health’s students and faculty into community engagement. That's a new direction.   

Can you give us an example of the power of community engagement?

When you look at public health, mostly we focus on curative care, like giving medicine, but preventive and promotive care are very, very neglected. 

For example, in Bangladesh, where tuberculosis is a stigmatized disease, they use community health workers to give those treatments. Community health workers can be a really powerful agent in the community because they are from the community and the community trusts them. They use the same vocabulary, they are close to the community.

We found that engaging those community health workers for maternal health care—for referring pregnant women with complications to the health facility—worked very well. Even for COVID vaccination: in Bangladesh, the COVID vaccination coverage is more than 90%. I’m very proud of that. It only happened because there is a structured effort to engage the community and the community leaders. 

So community engagement is very important if we really want better health outcomes for those who are vulnerable, those who are disadvantaged, those who are non-believers—there are people in this world who don't believe that COVID exists or that vaccines work—it's the community. We need to bring them on board and try to change their perspective.

You have long been a public advocate for these issues. How can researchers better communicate their findings to policy makers and the public?

When we do research, we want those research findings to generate a policy or an intervention. That's knowledge translation. The problem is that my minister of health doesn’t read the Lancet or the New England Journal of Medicine.

So it's very important to communicate to them. There is also the problem of the time lag. So what I published in 2023, the train has already left, because policy makers can’t sit there waiting on a researcher to publish. So we need more communication with policy makers and publishing is not the only way. Video, infographics, advocacy through Twitter/X and in the New York Times or the Washington Post are all options, although they are also often limited to elite populations. A school teacher in Missouri is not necessarily engaging on Twitter.

So I think that for public health advocacy, you have to be very creative and engaging. Those who are not very good communicators need to bring in partners who are good at communicating, and through collaboration, come up with different kinds of communication tools for different populations.

And because researchers have to acknowledge that communicating is not our skill, the language should not be researcher language. And we do need to bring in the communications team, those who do video, make posters or different kinds of communication tools. We need to bring them in and then allow them to communicate with different populations to disseminate the message, whether it's preventive, promotive or curative.

Tell us about the climate-related research you’re currently working on.

Bangladesh is one of the most vulnerable countries to climate change. We already had flooding and river erosion. Now, the flood frequency has quadrupled. Dhaka, the capital of the country with a population over 10 million people, is considered a heat island. 

For a climate change and health system resilience project I’m working on we look at how the health system responds when there's a flood, when there’s river erosion, when there’s a drought. So we’re looking at health workers, formal and informal, and also the experience of the population. We’ve interviewed climate migrants from the coastal areas coming to Dhaka. Their health-care-seeking behavior is very different. 

You’ve worked on tuberculosis, COVID, malaria, maternal health, mental health and now climate change. What is the common theme, do you think, that unites all your work?

I think I'm repeating myself, but it’s primary health care or preventive or promotive care—there's so much money and investment in cures, but there's much less attention to those frontline health workers who are always busy trying to improve health outcomes through preventive care.

So my interest is very much in looking at how primary health care, preventive and promotive care, can improve health outcomes. Navigating our health system from the community to tertiary care and looking at the implementation bottlenecks and the facilitating factors. 

Many people get interested in public health because so much of the world's suffering is preventable.

Yes, it's brought on by behaviors that maybe people don't know are harming them, or they don't care, or they haven't been educated, or they have been educated and they don't trust the messenger.

In the 21st century, we are talking about precision-based medicine, high technology, when 60% of the population doesn't have access to safe water and sanitation. I think we should be ashamed of that. I get mad sometimes that there are so many things we can do to prevent death and disability, but there's always a vested agenda. There's always a reluctance, particularly to save the vulnerable population, the disadvantaged population. So for me, I think we should focus on equity. We cannot make everybody equal, but equity we can ensure. 

In the U.S., African American women are many times more likely to die from pregnancy than white women. So why are more African American and Native American women dying from pregnancy?

It’s because of the social determinants, because they may be the poor, they might not have health insurance or access to health care. It's not biological. All women might have a pregnancy-related complication. But some women don't have access to care or health insurance to seek care or they can’t afford to buy medicine. So these are the determinants. It's not individual biology. Society determines who will receive better health care or not.

In South Asia and Africa, poor women develop cataracts. There's a high risk factor. Why is there a high risk factor? Because they use wood to cook. But it's not a risk factor for men, because men don't cook.

So the society determined that it’s the women's job to cook. So because of our gender role, because of our culture, religion, the social norms, we're exposed to different kinds of risk factors. And that not only causes diseases, that also influences health care seeking behavior, that influences access to health care, and ultimately that causes death and disability in this world.

You’ve spoken of community engagement here in Providence. Do you think the School of Public Health can bridge that gap?

The Brown School of Public Health, in my last 10 months experience, the school is going towards what it should be in the 21st century. There are efforts to connect students with the community through their field experiences, through teaching and even through research. Brown may be an elite Ivy League school but we are working closely with the Rhode Island Department of Health. That's unique, leaving the ivory tower to work with policymakers in the state to improve health.

I also think the school’s new accelerated MPH program for physicians is an initiative in the right direction. If you really want change, we have to change the clinician's mindset. So there are many ways I think the School of Public Health will be leading in the 21st century, engaging with policymakers, engaging with the community, engaging with implementers, bringing students, faculty, everybody together, because if we really want to improve health and ensure health for all, it, it requires all the partners to be on the same board. That excites me.

You've worked in North America, Africa, Asia. Do you have a place that you particularly love to work?

Professionally, I would love to work with any community, whether it's in Africa, Asia, Europe or North America. But personally, my favorite city is Heidelberg, Germany. So if I want to retire in the next 10-15 years, I want to go back because it's a lovely city to live in, and I really enjoyed living there with all my friends.

What have you learned from your experiences across all of these continents, through synthesizing all these different places in the world? 

First, how important the culture, context, language is for public health. Many problems are the same, you know, across all those continents. I would also say that it helped me to become a better person. I became more empathetic and compassionate because working with different cultures, in different contexts, with different populations, different religions, different ethnicities, I think made me more tolerant. The world is diverse and diversity makes it beautiful.