Nithin Paul MDMPH is a board certified family and preventive medicine physician practicing in Woonsocket, Rhode Island (RI). He is passionate about providing care in underserved communities and aligns his work of addressing the causes of health inequities with grassroots organizations that work to achieve people centered health justice. In December of 2021, Paul was among a group of activists and community organizers who slept in tents in front of the RI Statehouse demanding state lawmakers to take decisive action to address homelessness in the state.
Nithin Paul was interviewed by Shereece Rankine in 2023. The transcript has been lightly edited for clarity.
00:00:07
Shereece Rankine
All right. Thank you again Nithin for taking the time to speak with us today. I think we’ll start off with you just telling us a little bit about yourself.
00:00:25
Nithin Paul
Yeah, sure. My name is Nithin, I’m actually an immigrant, I came to the states from India, at the age of eleven. I always wanted to be a doctor when I was growing up, but then got interested in community development things. And my passion now is trying to find the connection between how communities are organized and how that impacts health. And so, I am currently working as a family medicine provider in Rhode Island, in Woonsocket. I’m trained specifically in family medicine, and something called preventive medicine, which kind of takes a little bit more of a systems analysis of our health structures. I am currently interested in trying to connect and draw the lines between primary care and community organizing, and seeing where that goes, and how we can build on that.
00:01:25
Shereece Rankine
Thank you. Tell me a little bit about what motivated you to become involved in social justice activism.
00:01:35
Nithin Paul
Yeah. For me, I was always interested in politics and societal movements. That’s something that was always there, and I was always drawn towards it particularly because I felt like my life has been changed by so many social movements, and by the structures that I grew up in. Growing up in India, you see the stark divide amongst different classes of peoples, and I never had a way to understand it. And so I think, as I started to kind of learn about it, whether it was in high school, college, or after college, I kept asking why things are the way they are? Why is this group of people more vulnerable than this group of people? Being someone who’s coming from a country that was colonized, it was often this question of how is my country of origin perceived? And how am I perceived because of that? And so there was a lot of stuff that was personal about it, and there was a lot of stuff that you see around you in society. I was always brought up to say like, okay, like you were supposed to help each other out. But you quickly realize that the system is stacked against some groups, and so a big part of it was just curiosity, asking why. As I started getting more into the work, all these theories and ideas in my head that I had at the time of why things are the way they are started to fall apart. I realized, you have to kind of really dig into the history of things. That really led me along into the way of thinking of social justice, as like a historical analysis or historical way of looking at why things are the way they are now, and trying to account for that, in fighting for the future. So, yeah, that all kind of came together.
00:03:31
Shereece Rankine
Okay, and how does your work as a medical doctor, and as an activist inform each other?
00:03:38
Nithin Paul
Yeah, I think it’s definitely something that the more time that has gone by, the more I realized that whether any medical provider acknowledges it or not, our perception of the communities we’re treating is directly impacting the type of care we provide as well, subconsciously or consciously. It also really affects how we think about the systems in which we practice. When I went into medical school, at that point, I had done a little bit of work in community development, particularly in India, and there were a lot of questions that were starting to bubble up for me at that time. I think I initially got into that work of community development with a little bit of the savior complex myself, and I saw quickly how harmful that could be and the problems that came with that kind of mindset. And so, I realized the communities had to be organized and have to be self actualized in their own way in order to truly find solutions to some of these long standing problems. So, when I went into medicine it was a bit of a disconnect because people would say no, no, no “I spent all this time understanding the sciences of diseases, and that’s how you really treat the disease.” That’s how you’ve got to spend your time. It felt weird to me that we would really skim over what’s now called social determinants of health that we will mention, but never really do more than acknowledge that oh yeah, actually, that does affect 90% of health, and healthcare providers only really can impact 10%. We actively acknowledged how little of an impact just a biological framework had on health care but we never did anything further to kind of combine those two together. So now in practice, I found that the more I understood the history of the community I was serving in. Being an immigrant, I’ve been moving around so much, I never felt like oh, my gosh, this is my community, I already know it. I always had to do a lot of work to try to understand the history, read books, talk to people, go to on the ground events, and try to kind of understand as much as I could about the community. And the more I understood about certain things that were going on, it actually helped me to kind of put things in context. For example, I practiced and trained in Baltimore, or just outside of Baltimore, Maryland, and there used to be, big steel mill industries there, and a lot of working class people who lost their jobs because the industry up and left; understanding that history and then seeing the pathologies of the disease, made things different. I could just say you have lung disease because you’re smoking or because you’ve been exposed to something. I could definitely talk about just that and try to treat it but I think that when I am able to connect with my patient more about what job did you use to do? What was that like? That seems like work conditions were pretty tough for you, and it actually allowed me to connect with my patients more, and that connection eventually kind of translates into trust as well. Now that trust is established, and that’s both ways, right? It allowed me to listen closer, and it allowed us to kind of figure out ways how we could solve that patient’s health problems. Whereas before, it might have just been like, nope, you just need this inhaler or why don’t you take this inhaler? and getting frustrated about that. And so, I think it started really impacting how I connected with my patients and how it connected with my community. It taught me a lot about the community I lived in, and it gave me a lot of insights because as a primary care provider, it’s a privileged position because people share the parts of their lives with you in a way that otherwise I would never have had access to. As I started understanding all the things people have gone through or survived, and all the systemic injustices that they’ve had to endure, it then leads to the social activism part. Now I know that this is going on, I can’t just sit back and go back to my day to day life. I have to think about what’s my role in this community? Because I am one of the community now whether I like it or not, and so, yeah, they’ve definitely been interplaying.
00:08:17
Shereece Rankine
Okay. And while you were in Baltimore, your social activism, a part of that included your presence at a protest, after George Floyd was murdered, and I think, while you were there, you were interviewed. And during that interview, you spoke about the “sadness” that you experienced when Floyd was murdered. You also said that “racism lives within institutions, and the healthcare system has long been complicit in this.” My question for you is, are there specific historical evidences that you’d like to highlight? And are there current or ongoing practices within the healthcare community that you believe continues to perpetuate institutional racism?
00:09:20
Nithin Paul
Yes, there are, you know, there’s so many examples to dive into about historically how it’s been done, and how that history, that legacy still lives on in the systems that we currently practice within. I always want to say my own involvement, or my own kind of evolution into social activism, into joining the Black Lives Matter protests was growth for myself but I myself had been part of the problem in so many ways. And I think the movement for Black lives specifically actually forced me to kind of do a lot more introspection and so, so much of this stuff, for me comes from this understanding that I too have been complicit in this, it’s not to kind of point the finger outwards. I really think of this as we’re all part of the systems, when we engage in it, we’re part of these systems. And we have to be willing to say that we too, have been part of the problem at some level, and that’s okay, like in terms of, I’m human. And what we have to do from that point is, once you acknowledge that, I feel is, I have to now start taking actions and do this reflecting, and acting kind of in step with each other to move forward from there. So with that kind of caveat, and when the Black Lives Matter protests started all the way back, from the Freddie Gray uprisings in Baltimore onwards, I definitely kind of started asking questions and started digging deeper into things.
In Baltimore, up until the mid 20th century, there were two waiting rooms. There was a waiting room for Black people, and a waiting room for White people, and Black people would have to wait until all the White people had been seen before even the first of them would be seen by a doctor at the end of the day. And that was a practice that was just accepted and kind of used in Johns Hopkins Hospital, which is supposed to be one of the top hospitals in the world. So, first of all baked into this system, the medical establishment bought into white supremacy, very clearly you could see that just from that one simple example. A more famous case is that of Henrietta Lacks where her genes were then used to kind of understand cellular molecular biology and genetics and allowed us to come up with a lot of breakthroughs but the scientific medical establishment never felt the need to acknowledge it, it was like, no, because it’s, it’s from a black person, so they don’t need to be acknowledged. Whereas if it comes from a White person, we know that there would have been statues and entire movies made on this stuff a long time back. And so, that was another way how it was historically structured, but then it gets even darker. I had recently, this past year, learned this example– the Holmesburg experiments at the University of Pennsylvania, this is from the 1950s, or 1970s. These doctors from University of Pennsylvania, scientists, doctors, they recruited people from the carceral system, who were actively in prison, mostly Black males, and they convinced them to be part of this experiment, where they would intentionally, this is hard to say even because of how gruesome it was, they would intentionally infect them with syphilis and just watch them over the years, to see all of the long term complications of syphilis. And if they did have some kind of side effects or some sequelae of syphilis, they would get a paltry monetary amount for their inconvenience, and this went on from the 50s into the 70s, that’s past the civil rights movement. This is just horrendous, because first of all, it’s incarcerated people who are already a vulnerable population, already targeting Black and Brown communities, and then they do these overt experiments, at one of the most reputable, supposedly reputable institutions, again, in the world. Just another example of historically how the medical field didn’t bat an eye at this idea that Black and Brown bodies were okay to experiment on because obviously, that implies that they were less valuable, they just didn’t see the same value in it.
Moving towards how it works now, there’s this thing of like, oh, no, we’ve come a long way, that was in the past, all we can do is look forward. And I remember I went to do my Master’s in Public Health at Hopkins, and I remember one of the former deans, even saying to us, they came and gave a kind of a small group talk with us, and I asked him, Okay, what is the role that Hopkins plays in collaborating with the community, and coming up with the solutions? Because Hopkins has this history of buying out all of these properties around the school, letting it deteriorate so it really brought property values down and pushed Black people out of those areas, so that they could then buy more land and really kind of gentrify the area forcibly, so all of that history is already there. So the question was in the context of that, and this person was a former dean, was like Yeah, I mean you know, we’re out there in the community, we have all of these collaborations and these multi stakeholder meetings and stuff and he’s kind of looking in our group (there’s only a small group of us), he’s like “I got to tell you it’s really difficult, you go in there, and these pastors are claiming we’re experimenting on them.” And he tells me, oh, come on that was like decades ago, what? like, we’re not doing that now. Like, we just can’t work with these groups, because they’re living in the past, and we’re trying to move forward. And to me, it was just this thing of like, wow, how easily, people are able to kind of just wash their hands clean, like, no, that was why that has nothing to do with me, get over it. Why aren’t you working with me? Look at me extending this olive branch and you’re refusing it, so that’s on you. People don’t oftentimes overtly say that so it was kind of shocking to me, for someone to just acknowledge that so openly, but I appreciate the honesty at the very least. And I think that kind of mindset is very prevalent now in a lot of these things.
And so, going back to medical school training, literally, you’re not taught about how social ills are the root causes of so much illness and because you’re not taught that, you train medical providers, who get frustrated by social complexities. And I have heard several of my colleagues or classmates back in the day say, “I love working in the ICU, because the patients are intubated and I don’t have to deal with any social complexities of theirs, I can just focus on the medicine.” And to me, first of all, no you can’t because it’s still impacting these patients, but secondly, how twisted is that, people are trained in a way that makes medical providers and physicians specifically kind of go ‘ugh I don’t want to deal with social problems when I’m trying to treat a disease’ which is insane, because we know now, we’ve known, it’s not just now but our structures, environment are 90% of what’s causing certain diseases and the majority of diseases that have been impacting our populations at large. And so why do people feel this way? And I think it’s because the system is a relic of its predecessors, like at a time when it was normal to have two separate waiting rooms for Black people and white people, at a time when it was normal to experiment on Black and Brown bodies. We’ve not had a revolution, there’s been no significant upheaval so why would we expect suddenly for them to have just automatically been like, yes, actually, everything we did was really messed up, let’s stop, pull the brakes and change everything. No, like, that’s just not how change works. Change has to be kind of demanded and not expected. And I think that’s kind of where my headspace was during that time period, and so when George Floyd was murdered, it was just so hard to watch, obviously, for everyone. But again, it was super important to tie it all the way from just that one moment in time, to this historical moment in time. And as a healthcare provider, I felt like we hold a lot of power in society, because of the way it’s been set up, because of the way the healthcare industry has lobbied for power. And I think we need to use that power now to go back and break down the systems of oppression, and rebuild them. So that’s where I was at.
00:18:59
Shereece Rankine
Thank you for your response, and for being so open about the issues as you see them. I appreciate your transparency. So, in thinking about a multi disciplinary approach to crafting policies, because we spoke about medicine, and we’re thinking about the social determinants of health, so bearing that in mind and thinking about a multi disciplinary approach to crafting policies, how would you engage lawmakers– and if we can go as far as to also include law enforcement– to think about racism as a public health concern?
00:19:49
Nithin Paul
Yeah, I think there are so many levels to enacting systematic change. And so if you’re talking about law makers and changing the policies and laws in place, there’s so many different things that have to fall into place for just one law to get passed. You need to have public willpower, you need to have political will, you need to have, quote unquote, what is called “feasibility”, right? Like, is this actually possible and doable? And so it’s within that context, I think any truly sustainable and real stuff that’s impactful in a meaningful way, I think would have to come from the ground up. Right? I think that while the ground level rises, it might take some time, or I don’t know what that would look per se. I think it takes on an organic form. In the meanwhile, we definitely pressure lawmakers at the top and try to do some top down changes as well. We can definitely try that. But, from my experience of doing a little bit of advocacy, going to state legislation hearings and giving testimony for different laws, where every time I’ve given testimony– for something like, not for profit hospitals should be required to disclose how much money they spend on public service and public goods because they’re getting all these tax breaks– what I remember when I was giving testimony on that, was that the people who were listening to lawmakers started parroting questions that the insurance industry and the hospital lobbying industry had already been putting out there. And I realized, like, oh, my gosh, the hospital industry has already gotten to these lawmakers. It’s like we’re just doing these questions and testimony things almost like a farce. I didn’t feel like they were actually listening, and the only way we would actually be able to make them listen is if they felt pressure, public pressure, specifically. And so there will be some lawmakers who make it through the ranks and are on the same page, but even they will be limited because you need consensus building. And right now, the systems are not allowing people who have these thoughts of like, hey, we need to deconstruct and reconstruct the system, to kind of get through. It feels to me that the majority of times, we are looking for incremental, small changes that pacify the public, but don’t necessarily change, or get at the root cause of things. So all of that to say that I think the foundation of all of this has to be community organizing, I really think that when communities come together, when they can find each other, when they can find common ground, you start to realize that there are more poor people in numbers than there are rich people by definition. And if you’re living in a democracy, technically, we could have that large power to actually reconstruct the system for ourselves, but the system is going to prevent that, to overcome those things to get people to come together and coalesce into a stronger bond. And so when we were talking about whether it’s police or lawmakers, I think they have to feel the power coming from outside of the institution, they have to feel that like whoa, something’s happening on the ground level, and if I’m a smart, savvy politician, I’m going to try and get ahead of it, and I’m going to try to give people what they want. In order for them to talk like that, we have to be organizing at the ground level I think. And so if politicians or anyone who’s in the systems of power, meanwhile, they want to do well, I think a big part of it is, they actually have to come down and spend significant amounts of time, not just one time, but consistently, for years on end, just listening to the people and communities on the ground, who are actively taking on these challenges. And I think when you come not to solve a problem, but to listen, and then you listen, and you listen, and you listen, I think over the years, it actually changes you. And I think that it gives you courage to take on systems in a stronger way. So, I think a big part of all of this stuff will come back to we can’t wait for lawmakers to grow a conscience, we have to force them to grow consciences, have their own interests, and whether it’s police accountability, you know, we’ll talk about good apples and bad apples. At the end of the day, I kind of see it as a system right? There’s a system that allows a group of people who are legally told you have to protect society with guns, and now are also pretty much told that we will take your word over the word of the people, right? That system is messed up. I don’t want to talk about the individual people in it, that system is not held accountable, you know, it’s not holding itself accountable. And so how do we do that? How do we get to that point? Again, I think it’ll require a sustained push from the ground level up and not just a push to change things, but it will require an alternate reality. We have to propose an alternate reality that makes the current one obsolete. And that’s going to require imagination, reimagining what our society could look like. But that reimagining, again, has to come from those who are oppressed by the systems, because I think that’s how you make it more equitable. When their voices are centered, it is far more likely to build an equitable system than if we have a top down approach.
00:25:44
Shereece Rankine
Thank you again, these are all the questions that I have for you. I think that the work that you’re doing is really remarkable. And I just wanted to give you the opportunity to add any final thoughts, if there’s anything you’d like to add or any big takeaways?
00:26:15
Nithin Paul
Yeah, I appreciate so much being given the opportunity to just chat. So much of these things that I’ve learned have come from movements. For me, I owe so much to these grassroots movements, whether it’s Black Lives Matter, or Indigenous rights movements, things like that, because I think the main thing I always think about for myself is that we can’t talk about things om just the abstract. And yet, we can’t act without thinking about things. And I think that’s what I’ve come to understand the word praxis as; the constant reflection and trying to deeply understand but then adding on an action based on the reflection, and then reflecting on that action, and kind of slowly building, building, building. I think one of the biggest things I’ve seen in healthcare is a lot of reflection, but not action, or actually the opposite, a lot of action, but not reflection, where people want to do good, they go into communities and use words like Global Health, which has become almost like a toxic thing, I think, at this point, because people are acting without reflecting on what they’re perpetuating, and their role in it. And so I think the one thing that I tried, that I found helpful for myself, has been this kind of reflection with people who can hold you accountable. To understand what my biases are, why are my biases as they are? Trying to really, truly understand and unpack that, trying to identify what’s my ego in this? and what’s something that actually reflects what I want to be? and then adding that action. I think adding that action requires a lot of courage; and I think courage comes from community. And so, you have to build community, with people around you that you respect, and who push you in ways that you want to grow. That’s what I hope we can all do; I think that hopefully will build those grassroots movements.
00:28:19
Shereece Rankine
Thank you, again, I really appreciate it.