Studying the Past to Understand the Present

Botelho began studying the organization and interviewing local scientists who had been involved in the early days. Eventually, she and two other historians created a collection of the organization’s best written works from the ’70s and ’80s, along with historical commentary.

“It opened my eyes to this community of scientists and physicians who understood that their work was deeply political and not separate from society, and wanted to channel it for the political and cultural good,” Botelho said. “I think their history offers lessons to current health care workers who want to critically engage in political and social issues with their work.”

As Botelho’s pursuits expanded, she revisited her plan to study molecular biology and become a doctor. Instead, she chose to double major in biology and the history of science.

“I’ve always been naturally curious about people, and how their social worlds affect their life chances,” Botelho said. “I began thinking about how I could combine my curiosity about people and my interest in storytelling with my wish to take care of patients.”

David Jones, the A. Bernard Ackerman Professor of the Culture of Medicine in the Blavatnik Institute at HMS and a professor of epidemiology at the Harvard T.H. Chan School of Public Health, offered her a roadmap.

Through Jones, Botelho learned about a robust community of doctors who are also social scientists studying fields such as anthropology, economics, epidemiology, and history, including the late Paul Farmer, Jim Kim, Arthur Kleinman, Scott Podolsky, Anne Becker, and others at Harvard and HMS.

“These people are caring for patients but also thinking about the big social structures that affect their patients’ health and the way we practice medicine,” she said. “I had an ‘aha’ moment that this was a great path for me to bring my interests together and serve the medical profession.”

Lessons from history

With that realization, Botelho entered the MD-PhD program at Harvard, pursuing dual degrees in medicine and history of science.

“As an MD-PhD, you’re both acculturated in medicine and an observer or studier of it, so you have to be able to toggle between those roles. I think being able to do both benefits me in both spaces,” she said.

Her research has taught her to think deeply about the reasons why patients seek treatment, and what other challenges they may be facing. Her work with patients has informed the questions and issues she chooses to study.

“Seeing patients from different backgrounds and life experiences has helped hit home the idea that people don’t come into the clinic from the same starting point,” she said. “You have to be able to think and act upon the forces beyond the hospital or doctor’s office.”

It was the 2016 presidential election, however, that propelled Botelho to study rural health care systems. Following that election, rural America was placed under a magnifying glass because of its role in electing Donald Trump, she said, just as the U.S. opioid epidemic was devastating rural communities, and many rural hospitals unable to stay afloat financially were closing.

Botelho felt that the news coverage on rural hospital closures lacked nuance, and studying the history of rural health care systems was a way she could illuminate the discussion.

“I wanted to bring a social justice lens to the history of health infrastructure in rural areas,” Botelho explained.

In particular, she wanted to tell the stories of rural communities and hospitals not often portrayed in the media, including Black and Native American communities. She said she also wanted to explore how white supremacist politics had impeded the development of rural health care systems.

To do this, Botelho sifted through mountains of historical documents, and spent countless hours on the ground in rural hospitals talking to health care providers and patients. She then wrote a series of in-depth historical case studies on rural health care systems throughout the United States.

Read the full transcript (PDF)

Her first big takeaway?

“Rural America isn’t a monolith,” she said.

Instead, how people experience health and disease in rural places differs based on identities such as race, gender, class, and indigenousness. Moreover, rural geography layers on top of other legacies of disenfranchisement to create the worst health outcomes for the most marginalized rural communities.

Her second big takeaway?

“The problems facing rural hospitals today are not new problems,” she said, but ones that have existed for over a century.

One reason for this, she believes, is that the U.S. health care system prioritizes market freedom and local autonomy over equal access to care, which can harm rural hospitals that lack money and resources, even though many in rural communities support those values.

As the COVID-19 pandemic arrived, Botelho’s research on the long history of struggling rural health care systems suddenly collided with a present-day health crisis. In Great Falls, political and cultural divides emerged around masks and vaccines, while the hospital faced staffing shortages.

“I was able to see how decades of neglect and disinvestment in rural health infrastructure led to this moment, when rural communities really struggled to fight COVID-19,” Botelho said.

The experience only reinforced for her why examining medicine from a historical perspective is so important.

She hopes that her research will offer policymakers historical lessons that they can use to develop more effective strategies for improving rural health care. She also wants to share what she’s learned with medical providers and the general public who may be unfamiliar with rural health care issues.

Read the full transcript (PDF)

Charting a path

After spending a combined 13 years at Harvard and HMS, Botelho will continue her training as a resident in internal medicine primary care at the University of Washington in Seattle. There, she will have an opportunity to practice medicine in rural communities throughout Wyoming, Washington, Alaska, Montana, and Idaho.

Primary care felt like a natural fit for Botelho, who realized during a clerkship at Cambridge Health Alliance that she wanted to forge long-lasting, in-depth relationships with patients, and help them make health care decisions based on their own goals and values.

In internal medicine, Botelho will be able to “think broadly and holistically about a patient’s entire social world — everything that’s going on,” she explained, while also working with specialists to provide care.

Botelho’s long-range goal is to become an academic primary care doctor and educator who divides her time among her passions, including teaching medical students and residents about health equity and social medicine, researching and writing about historical issues in medicine, and of course, treating patients.

“It will take me time to think about how all those aspects of my career will come together, because there is no formula,” she said. “The exciting part of the next few years is figuring that out.”