Prakash Ganesh, MD, a family and preventive medicine physician, is devoted to serving communities in Northeast Ohio and around the world. He wears many hats, as Medical Director of the Cuyahoga County Board of Health, Associate Director of the CWRU/University Hospitals Preventive Medicine residency, practicing physician at Neighborhood Family Practice, and CHI Center faculty member. He and his family returned to Cleveland in 2019 after four years in Malawi, where he provided care at the country’s largest refugee camp, consulted in a tertiary hospital, and supervised local HIV and tuberculosis care.
Q: What was your path to medical school like?
A: Many members of my extended family are in healthcare. My mom is a nurse. But I didn’t initially want to go into medicine. I actually was a physics major with a minor in history, but I realized that I really enjoy working with people, I enjoy knowing their history. And I like teaching. I feel like, as a physician, I’m always teaching and learning. I wanted to build relationships and help people, and I think that’s what made me pursue medicine.
Q: I know you’ve devoted part of your career to global health. Did that interest start before medical school?
A: Yes. I wanted to travel, not just for tourism. I wanted to help people around the world that might not have the same access to care or education that we have here. I felt like being able to travel and work would be amazing and exciting.
I went to medical school in the south of Israel. The school focused on global health, and it was located in a very diverse part of the country. We had a lot of refugees who came through Africa and would cross the Sinai Peninsula, which was pretty rough. In addition, there are a lot of Bedouin communities around the area.
Q: That sounds fascinating.
A: We also did a rural rotation in another country, so I was in India for about two months during my final year of school, in a really small town. I was based at the Mahatma Gandhi Institute for Medical Sciences, which focused on providing primary care for rural communities. We would set up our clinics around town and people would line up.
I remember hearing at the time that polio was eradicated, but in some of these villages we saw little kids with polio or the effects of it. It was eye-opening.
Q: Are these the kinds of experiences that led you to pursue a residency in family medicine?
A: Yes, I was interested in general surgery or family medicine at the time. I did several general surgery rotations here at Case Western, and I didn't really enjoy the type of care I was providing. I felt like I was an operator or a machinist: “Do the procedure, get it done, move on to the next one.” I didn’t feel like the focus was on the patient. It just wasn’t a good fit for me.
Q: You completed two residencies, right? Family medicine and preventive medicine?
A: That’s right. And in my fourth year, for the preventive medicine portion, I was allowed to spend some of that time in Malawi [in Sub-Saharan Africa], where I did my capstone. Since I had already finished my family medicine residency, I was one of the attendings on the internal medicine service in the main tertiary hospital in Malawi. I also started a clinic in the Dzaleka Refugee camp, about an hour north of the capital of Lilongwe. This refugee camp was one of the worst I've seen: no electricity, no running water, most of the houses were made out of mud. I would do home visits, but otherwise I had a clinic and people would come to me. It was hard.
Q: So the clinic was essentially you?
A: Yes. I just carried a blood pressure cuff, a pulse oximeter, a thermometer, an ultrasound, and a bag of medication that I would prescribe and teach patients to use. I usually had an interpreter. I also became a liaison between the hospital and the refugee camp.
I ended up taking on another job through the University of Washington’s I-TECH [International Training and Education Center for Health] program. I focused on capacity-building, training mid-level providers in adult and pediatric HIV and TB care. And I was seconded to the Lighthouse Trust, which is a Malawian organization. They had strict reporting requirements, so I helped monitor all our programs, made sure we were meeting our targets and would help present those to the CDC, and I helped write up proposals for other funding opportunities. I also helped represent the organization at the national level at meetings and served on various task forces.
Clinically, I taught by the bedside. If a clinician had a patient they needed help with, they would ask me and I would assist them in managing the patient. Otherwise, I was always trying to help bolster the inpatient TB ward. It was challenging but I learned a lot and it became my ward. I ended up putting in data systems to monitor who we cured, how many patients we had, and keep track of our mortality. We had a lot of deaths.
Q: What an experience. What do you think you learned or gained? What’s your pitch for working internationally?
A: It was a hard experience. I learned a lot about being adaptable, working with limited resources and in challenging environments, caring for the most vulnerable, and advocating for my patients. But I was getting burned out.
Q: It must be incredibly intense work.
A: Absolutely. My wife and I have actually been talking about this recently. When we were in Malawi, she did fistula surgery to repair the results of birth trauma. The essence of her job was curing people through surgery, so they had an outcome that was good most of the time, even if the surgery didn't completely help. But for me, most of the illnesses I saw were chronic. You don’t see the benefits right away, or ever. I might see one or two great outcomes over several months or years, but otherwise you don't see that immediate improvement and impact that you're making. That was getting kind of hard. I was getting angry when I saw patients suffering or being mismanaged, and it happened all the time. It’s why I was feeling burned out and started looking for a change in positions. It’s a big reason why I moved back to Cleveland.
Q: How long were you back before the pandemic started? Seems like you went from one kind of intensity to another.
A: I had a little bit of time off at the end of 2019 and it was a nice relaxing time. I started working at Neighborhood Family Practice in January of 2020 and my Case Western appointments came through in February. Not long after that I furloughed from my clinical practice for about eight months and worked at the Cuyahoga County Board of Health with Heidi Gullett, Johnie Rose, Kurt Stange, our students and preventive medicine residents, and the team.
Q: What was your role on the pandemic team?
A: I was on the preventive medicine residency team, and I helped manage outbreaks in various settings. Under Heidi Gullett’s leadership, we set up a system for managing Covid outbreaks, helping with diagnostics, then moving towards vaccination.
Q: It probably wasn’t the relaxing transition from international work that you dreamed of.
A: It was eye-opening. I liked working with the community and I’m interested in outbreaks. I actually had considered applying to the Epidemic Intelligence Service [of the CDC], but Heidi got me to thinking about coming back to Cleveland.
Q: You’re very much in two worlds: the world of medicine and the world of public health. What would you like to see the relationship between those two fields look like?
A: I think it’s an important question and it’s a line I’m always trying to balance. I feel like my work in Malawi was a good introduction to both public health and clinical medicine, and good training for what I do here. In clinical medicine we’re used to just getting up and doing things. On the public health side, I’d like to see the health department out in the community and educating people. That can help improve health, literacy, knowledge about medical problems and create healthy communities, prevent disease, and build up that trust with the public health and health care systems.
Q: Putting on your public health and medicine hats, what do you think are some of the key issues facing Cuyahoga County?
A: I feel that racism and health disparities are some of the biggest things that underlie many of the issues we face in public health, in the county and nationally.
Through our data, we’ve seen these factors in nearly all health indicators and in the Covid and mpox responses. We need to make sure we’re collecting the right data to show us what's truly happening and to guide us, and that’s sometimes challenging.
Another challenge is that, at the Board of Health we’re focusing on the county, but each municipality has their own challenges with health equity and social determinants of health.
Q: Is there anything you’d like to pursue in terms of your own research?
A: I’m not sure what the research world holds for me, to be honest. I feel like my focus changed when Covid happened; a lot of my research has focused on that. I’m in the Primary Care Champions program at MetroHealth, which helps train primary care physicians in various aspects of research, quality improvement, and health care systems, and I find my interests falling under infectious diseases, public health, and health disparities.
I’m happy with my roles at the Board of Health, my HIV practice at Neighborhood Family Practice is building up - I have a lot of continuity with my patients, and I’m doing a lot of hepatitis C treatment. I’m part of a State of Ohio program where we’re training primary care providers to get more comfortable managing hep C within their own clinics. I was the first one in the state to start prescribing under this program and I did a talk last week to try to inspire other people in primary care in managing hepatitis C in their own practices and reducing barriers to care for these patients. I’m trying to find research that fits in with all of that.
Q: I know this is a big question, but what’s your ideal view of where you’d like health care to be heading?
A: That’s a hard question! So much needs to happen. We need better data systems, we need improved communication between EMRs [electronic medical records], we need less vertical systems. I feel like all of our systems are disjointed. I wish public health and hospital systems were able to exchange information easier, that we weren't so siloed and it was easier for us to work together. I wish our health insurance system made more sense. I think many of these things would help a lot with serving our community.
Q: As I think about the different areas that you’re involved in - family medicine, preventive medicine, global health, public health - I wonder if there’s a particular thread that ties them all together in your mind in terms of what you think health care should be.
A: What I think ties my work together, and I might not feel it all the time, is social justice. It’s my way of providing social justice or helping fight the fight. And that's what I really appreciate about my different roles; I have the ability to work at a personal level with individual patients all the way through to working at a community level. I appreciate being able to have that spectrum and influence.
I was on a global health panel yesterday at the [CWRU] medical school and I implored the students, and I tell residents this too: when you guys work in global health, you are teachers, so you need to soak in everything you can now. This is the one time when people are dedicated to teaching you, so you need to take as much advantage of that as you can.
There are countries where people are thirsting for more of an education and patients are depending on their providers for their medical knowledge. No matter what you do in healthcare you are always teaching.
In global health, I saw that as my biggest contribution. Not only to other providers, but to my students and patients as well. And I was able to have that voice to advocate for my patients. I guess that’s my way of providing some kind of social justice for patients that usually don't have a voice, here or in a global setting.