VO LU M E 7
ISSUE 1
Oct obe r 2 013
Department of Medicine
Global Health
MEDICAL EDUCATION IN THE GLOBAL VILLAGE
A publication for all those
No Doors, No Drawers
who support medical
An Essay by Kate Venable MD, CTropMed®
education, clinical care and research in global health
No Doors, No Drawers An Essay by Dr. Kate Venable Continued on Page 6
Faculty Highlight Page 2
Alumni Spotlight Page 5
Resident Highlight Page 9
It was some time after I left Peru when I realized that the remote indigenous people with whom I had the privilege to work have successfully existed for hundreds of years with no doors and no drawers. They do not rely on keys or locks; they have no towels or sinks. They live with their environment, for better or worse, not excluded from it. They are completely dependent on the River in the Amazon Basin for water and fish, for bathing and washing, for the plants and animals of the jungle, for practically every aspect of life. And have been for hundreds of years. To put this in context, I joined a community development team that has been meeting yearly with this people group in the Amazon Basin of Peru. Though it was my first year as part of the team, these “Annual Meetings” – focused on health, literacy (the initial connection which spurred the Annual Meetings), agriculture, art and spirituality—were initiated several years ago by the community itself, with support of Peruvian and foreign volunteers. Continued on page 6
G l o b a l H e a l t h Fo o t p r i n t to go live November 1 We are excited to announce the upcoming launch of our new Global Health Footprint map project, set to go live on our website November 1st. The purpose of this exciting project is to document our activities around the world, for ourselves as faculty, our residents, and external audiences.
Intern Spotlight Page 10
Events/Announcements Page 13—14
You can find the Global Health Footprint by following visiting the Global Health website at www.globalhealth.umn.edu
Faculty Highlight Michael Westerhaus, MD, MA Assistant Professor, Department of Medicine
Pat Walker, Global Health Pathway Associate Program Director; Bill Stauffer, Global Health Pathway Course Director; and Brett Hendel-Paterson, Global Health Pathway Online Course Director
D i r e c t o r ’s Note Welcome to our updated and expanded Global Health Pathway newsletter! Inside our latest edition you will hear from residents, faculty, our global health chief resident and others about the amazing teaching, clinical care, volunteer work and research being done by global health residents and faculty. “Where in the world are we?” is often the question we are asked. With this issue, we are launching a new “Global Health Footprint” map to try to capture the depth and breadth of our work both domestically and internationally. You can search for us by topic – such as clinical care, teaching or research – and also by location. If you want to know, “What are we doing in Uganda”, it should be easy to get a quick sense of our work there. If you search by topic: HIV, for example, you will learn about Dr. David Boulware’s ground breaking research on cryptococcal meningitis and IRIS. Enjoy this issue! Patricia Walker, MD, DTM&H
For those who know me, I’m big into knowing people’s stories. I love the opportunity to listen carefully to patients narrate their encounters with illness and wellness. I love working to build community that draws on the strengths of who people are. And I love thinking, teaching, and writing about how society, culture, and politics influence people’s stories. But, when it comes to sharing my own story in global health as Pat and Mahsa have asked that I do here, the keyboard feels much more sticky and prone to typos. But, here goes… I’m from rural, central Minnesota. I grew up in a family of six with three siblings. Both of my parents are educators and deeply value learning, service, and wonder about the world, all things that most certainly sent me into the world “with wings” as my Dad is fond of saying. Unabashedly, excitement about science grabbed hold of me in Middle school and launched into successful science fair projects on oil spills and teeth. While horrible for my scores on all measures of high school popularity, my science fair projects won some state -level awards and even resulted in a trip to Lake Ontario with Robert Ballard, the oceanographer who found the Titanic on the Atlantic floor. During my high school years, I also ventured to Germany as a foreign exchange student and came back with a deep appreciation of the endlessly creative ways in which people could live. My interest in science and wonder about the world then took me to Washington University in St. Louis for my undergraduate studies. I started off thinking that I would get a PhD in biology, but endless hours spent mapping rat brains in a dark neuroscience lab convinced me otherwise. A trip to the Dominican Republic with a group of surgeons, fortuitous conversations with physicians doing international health
work, and a growing passion for social justice inspired me into the field of medicine. I also met my future partner, Amy Finnegan, at Wash U and we co-dreamed about getting ourselves out into in the world after finishing our academic studies. After college, we moved to Masaka, Uganda for one year (2000-2001). Purported projects on sanitation and education gave us cover for a year of immersing ourselves in Ugandan life and learning about the strength of community, cultural difference, the trauma of the AIDS epidemic, and warm hospitality. That year also gave birth to a gnawing unease with the way the world was structured. While there, a friend doing Peace Corps in Haiti sent us a letter telling us about an inspiring physician he had met in central Haiti by the name of Paul Farmer and included an article Paul had written called “Medicine and Social Justice.” Differentiating charity, development, and social justice interventions, the article spoke deeply to us as we reflected on our experiences in Uganda. We moved to Boston after our year in Uganda, where I soaked up as much time with Paul and the whole Partners in Health team as possible. I served as a case worker with PIH’s local community health worker program in Boston. I researched the World Trade Organization and Free Trade Agreements and their potential deleterious impact on access to antiretroviral medications throughout the world. I learned about the practice of clinical medicine in resource-poor settings through rotations in Rwanda, Haiti, and Lesotho. And I completed a master’s in medical anthropology because I wanted time to more deeply think about how the social structures of the world influence health. Eventual participation in the Global Health Equity residency at Brigham and Women’s Hospital gave me the chance 2
Mahsa Abassi, M.D. Global Health Chief, 2013‐14
Chief Resident’s Corner The Consortium of Universities for Global Health (CUGH) has defined global health “as an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide”.
Above: Ciara, Mike, and Amy – on bikes in Copenhagen, June 2013 Right: Amy, Ena, Ciara, and Mike – In Minnesota, August 2013
for sustained presence in Northern Uganda, working to understand how to reinvigorate primary care after twenty years of war. All of these experiences taught me that health and illness emerge through the biosocial, essentially the interaction of the biological and the social worlds, and that making strides in improving health requires continuous, long-term partnerships with patients and communities. These lessons inspired me to pursue primary care because of the opportunities for front-line, in-depth, and longlasting relationships with patients. I am thrilled by the unique opportunity to practice primary care at the Health Partner’s Center for International Health, where the global is most definitely local on a daily basis. These lessons also motivated the creation of the organization SocMed. In collaboration with Ugandan colleagues, Amy (now a sociologist) and I founded SocMed to advocate for and implement health professional curriculum founded on the study of social medicine (www.socmedglobal.org). Integrating the principles of praxis, the personal, and partnership, SocMed offer annual courses in Uganda and Haiti that merge social medicine and clinical tropical medicine for students from all over the world.
On the personal side, Amy and I have been married now for 11 years. Amy is the faculty Department Chair of Justice and Peace studies at the University of St. Thomas. We have two wonderful daughters, Ciara, a lively, engaged 2 ½ years old, and Ena, a very sweet 12week-old whose personality is still unfolding. We love the outdoors, travel, and bicycling. We both love the ability to bicycle commute to work from our neighborhood in south Minneapolis. Arthur Kleinman, a mentor during my studies in medical anthropology, once told me that “Anthropology isn’t really all that good at providing answers. It is much more about getting people to ask the right questions.” I like to think of that as my motto for my work at the Center for International Health, in SocMed activities, in my role as faculty in the global health pathway at the UMN, and in my personal life too.
As a recent graduate of the Internal Medicine Residency program and the first Global Health Chief Resident I have had the immense privilege of working alongside faculty who have dedicated their lives to global health as well as a diverse group of residents. Recently I was preparing a presentation to highlight our global health pathway for applicants applying to our residency program. As I was preparing the PowerPoint, I found it interesting to reflect on the roots of the global health pathway from its inception in 1981. Thirty two years later, we have grown to have international partners on four continents; 300 hours of online learning modules; a well renowned in person global health course, and a chief resident position. Please check back for updates to our regularly dispersed newsletters regarding the Global Health Pathway. Like us on Facebook at University of Minnesota Global Health Pathway Follow Us Twitter @UMNGlobalHealth Subscribe to our Blog at http:/umnmedicineglobalhealth.blogspot.com/
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G l o b a l H e a l t h Pa t h w a y @ Hennepin County Medical Center Ron Johannsen, M.D., Director of International Medicine, HCMC I have the honor of coordinating Global Health activities for our Internal Medicine and Emergency Medicine/Internal Medicine residents at Hennepin County Medical Center (HCMC). My wife, Colleen, and I travel overseas approximately four times per year for approximately one month per trip teaching at hospitals in the developing world. The majority of these sites are in sub-Saharan Africa. We have the opportunity to work with our residents who accompany us overseas on these trips as well as encouraging their international medicine careers when we are back at HCMC, where I work in the department of Internal Medicine/ Division of Cardiology. Last year, four of our residents had the privilege of taking the University of Minnesota Global Health Course, where I and a number of our Hennepin faculty have the opportunity to teach. Our residents in the Global Health Pathway at Hennepin spend one month overseas during their residency training and receive a stipend from the Department of Medicine to help support these trips. Last academic year, our residents spent time teaching and learning in Haiti (Dr. Melissa ), Gabon (Dr. Melanie Lo and Dr. Brandon Hayes/Univ of Mn Peds resident) and Nepal (Dr. Brian Frederick). Dr. Brian Frederick was awarded an academic aide position at the 32nd Annual Continuing Medical and Dental Education Conference, which was held in Chiang Mai, Thailand in February 2013. This is an annual international medicine course that provides 9,000 CME credits. I am privileged to be the Academic Dean for this conference, and, although I am biased, I feel it is one of
Drs. Hayes and Lo at a muddy elephant crossing site along a costal road in southwestern Gabon.
Dr. Melani Lo at Bongolo Hospital in Gabon with nursing staff, Dr Johannsen, and patient (permission for photo by patient) teaching about her area of research interest
the best and most comprehensive global health courses in the world. We have an excellent core of Hennepin physicians who are highly supportive of the Global Health Pathway, including but not limited to Drs. Carmen Divertie, Hernando Gonzalez, David Williams, Steve Dunlap, James Leatherman, Anne Pereira, and Meghan Walsh. A couple of the ongoing, overseas research projects include use of inferior vena cava measurements for rehydration protocols prior to chemotherapy in children with Burkitt’s Lymphoma to decrease tumor lysis syndrome. In the last fourteen children where this protocol was initiated, we have had 0% 30-day mortality compared to the historic control of
Global Health
Dr Brian Frederick evaluating a leprosy patient (permission for photo by patient) in Nepal
28% 30-day mortality in this Cameroonian population. Other research efforts include the study of a rapid, portable single view ultrasound screening for secondary rheumatic fever prophylaxis. This study is being done in Kenya and Cameroon and will, hopefully, bring about changes in how we approach rheumatic heart disease in the developing world in a cost-effective and more “upstream” approach. In a future global health newsletter article, we will highlight activities of the current academic year. It is good to be part of this Twin Cities community of providers with a special interest in international and immigrant health as we encourage and learn from one another. 4
Welcome Chhabilall T. Sharma, M.D.
Dr. Chhabilall Sharma
We are pleased to announce that Dr. Chhabilall Sharma will be the international site coordinator for our Nepal site. Dr Sharma is originally from Nepal, and worked for 8 years with UNHCR in Nepal, caring for Bhutanese Nepali refugees. He completed his psychiatry residency at Hennepin County Medical Center in 2011, where he served as Chief Resident in psychiatry. He is currently working as a psychiatrist at HealthPartners, and spends part of his clinical time at HealthPartners Center for International Health. The Nepal site is co-directed by Dr. William Stauffer, and is an outstanding opportunity for residents to work with the International Organization for Migration. IOM is responsible for screening refugees prior to coming to the United States. Residents can work with IOM, as well as see patients at Damak Hospital. Please join us in welcoming Dr Sharma to the global health faculty.
Alumni Spotlight Nate Bahr,. M.D. I came into residency with a strong interest in global health driven by the interplay of social justice and infectious diseases. I had experience working in developing countries on water supply and sanitation, as well some clinical experience as a medical student, but very little clinical research experience. At Minnesota I’ve been fortunate to work with Dr. David Boulware and his team in Uganda and South Africa on a number of projects related to Cryptococcus meningitis (CM). We’ve presented work on an accurate, cheap, heat stable, and rapid Cryptococcus antigen detection assay (perfect for the developing world!), the possible use of tonometry in patients with elevated intracranial pressure and methods to manage electrolyte deficits induced by the Amphotericin that’s needed to treat Cryptococcus. Most importantly, the WHO utilized our work with electrolytes for inclusion in their treatment guidelines, which should influence policy in countries around the world and lead to better outcomes in CM.
Nate Bahr and Kate Gillen in Port-Au-Prince Haiti working at Hospital Bernard Mevs with Project Medishare.
Our focus for my time in Uganda will be to use the Gene Xpert® MTB/RIF cartridge (a fast easy PCR based assay) to attempt to diagnose TB meningitis. This assay has been rapidly deployed around the world for diagnosis of pulmonary TB and rifampin resistance (which has been thoroughly validated). TB meningitis is difficult to diagnose and patient outcomes are poor in part because the diagnosis is problematic. We hope to help improve the speed and accuracy My prior work with Dr. Boulware made the U of MN an at- in diagnosing TB meningitis to allow earlier treatment and tractive place for me to stay for fellowship (although there’s improve outcomes. plenty of other reasons I wanted to stay!). Being certain The Fogarty award allows me to dedicate the initial year of that I would be working with a great mentor that I could my ID fellowship to a clinically important research question trust to guide me with my best interests in mind was invaluin a developing country. This year will help me to better able in the decision making process. In addition to ID felunderstand my career path and hopefully improve care for lowship, I decided to apply for a Fogarty International Rea condition that disproportionately effects people in the search Fellow position through the NIH. developing world. Medicine is all about using our skills as I’ll work a team in Kampala that I know well who is dedicat- physicians to improve the lives of our patients. In my mind ed to improving care for conditions that are devastating we should have a special focus on those persons whose underserved populations worldwide. Because the Fogarty social conditions have made their ability to live healthy lives award is geared towards work in developing countries it will more difficult. The opportunities available to us in the globprovide additional research and infrastructure funding to al health pathway have allowed me to continue my training make a lasting impact in Kampala. with that focus on underserved populations in mind. 5
No Doors, No Drawers
Sunset over the Chambira River, Amazonas Peru
Continued The indigenous community had been working with a literacy project, and through that connection, became interested in growth in other areas of life. Prior to the Annual Meetings this jungle community had encountered the “outside world” through various avenues: the literacy outreach project, oil-seeking businessmen, anthropologists eager to study their cultural practices, jungle eco-tourists, service-oriented medical teams offering miniature floating clinics, and the Peruvian government—trying to somehow bring indigenous peoples under its authority while still allowing them a degree of autonomy (quite a topic, and beyond the scope of this small essay). Some in this group had sought medical attention from physicians in the cities, though they are the exception, and some of them had likely been exposed to basic health education. Community Health Workers (CHWs) from each community had been appointed by the Peruvian government, but typically received little training along the way. In hopes to augment their training, the indigenous leaders requested that the Annual Meetings include further training for the CHWs on potable water, basic health concepts, and common conditions encountered in their villages. This
ods for purifying their own family’s water. One of the 20 CHWs volunteered that he uses a small amount of bleach in his water. No one else spoke. Many eyes averted the teacher’s questioning gaze. The volunteers listening sat in silence as well. This was profound. It did not take long to calculate that this one man represented 5% of the CHW’s in this community (of the ones attending the Annual Meeting, but likely a reasonable sample)… and that only a very few were implementing what they had been taught regarding water purity and disease. The silence was soon broken, and the CHWs were asked why they were not treating or boiling their water when they had been taught that it makes them sick. Their responses were along the following lines: “We have been drinking from the River for hundreds of years – why should we cook the water now?”
“…[they] had existed successfully for hundreds of years with no doors and no drawers… no keys or locks, no towels or sinks. They live with their environment, for better or worse, not excluded from it” ~Dr. Kate Venable had been done in the few years prior, using a community assessment tool called the “Ten Seed Technique.”1 All involved (foreign and CHWs alike) recounted tales of how gratifying and helpful it was to learn the indigenous peoples’ perspective on their health needs, causation of disease, and the health priorities held by the community leaders.
“What do you [read: gringos] know about our river? We live in communion with the river for every part of our life. You do not know the river like we do.”
When the CHWs came together at this year’s Annual Meeting, discussion continued on some familiar topics. While revisiting illnesses associated with non-potable water consumption, the question arose about how many among them regularly implement previously taught meth-
This one CHW who treats his family’s water voiced, “My children used to dislike the taste [of the bleach-treated water], but now they drink it and we are not often sick.” This change – 5% of the CHW’s, not the general community Continued to next page
“My children don’t like how the water tastes when we boil it [implied: over the coals and fire, in the same pot we use to cook food] – it tastes like smoky fish.”
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Setting out on the boat-taxi, with the team for the Annual Meeting
- had come after several years of teaching, being previously given the opportunity to see with a microscope that more exists in water than what we see with our eyes, after receiving education about cause of illness, hygiene and the health concepts we in our culture may even view as common sense. The scene closed shortly thereafter, as the sounds and smells of lunch offered a natural escape. (And I recall it actually may have been smoked fish that day…) The CHWs dispersed, the volunteers packed up their teaching materials, and we made our way to the dining area for lunch. No more conversation over potable water would be had for the remainder of our time with these CHWs. Enough had been said.
spite of their differing beliefs about disease causation? Is it appropriate to give albendazole, explaining that it kills the “bichos” when they are drinking the river water to wash it down? Do we perpetuate dependence on foreign aid and perceived powerlessness by bringing “free” treatments and offering “free” medical care? (Reality is, of course, that both have a cost. What’s more, patients are not, in most cases, utterly destitute and could bring something to the table?ii) Would it be better to suggest that each family bring something to contribute to their medical care – for example: a bushel of plantains, a woven mat? Or work with them to use local avenues for health care?
The humility and courage of this lone CHW continues to captivate me. The objections and honesty of the others likewise speak a clear message. Even today, I am still trying to What is the effect on the local economy when we bring suplisten. plies from the US to give away free to patients, Why had lessons about river water and diarrheal illnesses not “sunk in?” Why had the concept of pure, clean, “bichosfree” water not caught on? (“bichos” is a regional term for parasites or worms) I return again to the phrases with which I started: No doors … no drawers. This “snap-shot” illustrates to me that we live in completely different environments, cultures, and belief-systems, and that apparently more is needed than education to produce change in such fundamental ways of life. My reflections have stirred up many other questions regarding my own personal approach to global health work in general. Here are a few: Do I honor and serve people, respecting their dignity as human beings, by applying allopathic methods in
who, without my free offerings might find a way (resourcing within their community) to access their local clinic, thus supporting its existence? What will they do with the little plastic bag of amoxicillin I give them to treat their (maybe) pneumonia? Since there are no drawers, no doors - where will it stay? How will it not become wet like everything else during the two-day canoe journey back home when the daily rains fall? What happens when a patient’s cultural values promote sharing equally among all family members, and Continued to next page 7
Landscape along the river in the Amazon Basin of Peru
therefore entitle each to a dose of amoxicillin that was intended for one child’s pneumonia? Are there ways we could better address health needs, taking into account environmental concerns, resourceappropriate treatments, belief systems surrounding disease, local geography and culture? Does this specific people group simply need more time for that one CHW to model his water treatment to his village, demonstrating how his children aren’t sick with “bichos” any longer, so that the villagers believe him, and follow his example? These questions are uncomfortable. They reveal potential unwanted outcomes of our efforts to help and teach. I don’t have answers to these difficult questions. But I believe they need to be asked – if nowhere else, in my own life – as I consider what sort of involvement I want to have in the Global Health arena, both at home and in the jungle. And the truth is, after some reading and literature review, I discovered that similar questions are being raised by a number of voices aside from my own. In my search, a friend (who is on the
board of directors for Doctors for Global Health, an excellent organization doing solid work empowering local communities in health and development) called my attention to the following article: “Rules of Engagement: The Principles of Underserved Global Health Volunteerism” by Dr. John Wilson and colleagues at Mayo Medical Center in Rochester, MN.iii I commend it to you. They examine key principles in view of medical education. Another excellent perspective is a documentary regarding aspects of development in Sierra Leone entitled, “They Come in the Name of Helping,” and another entitled, “First, Do No Harm” which addresses medical work done by foreigners and medical students in lowresource countries. Further research in the arena of global health work (primarily short term, with a medical education slant) has produced several on-line courses focused on ethics of short-term medical work and international health electives, which I highly recommend (see http:// ethicsandglobalhealth.org/ as an excellent example). After the scenes I described above, my group of volunteers (Peruvian and foreign) began some difficult discussions on these sensitive matters. I don’t question the intent of my Perubased team, or others of which I have been a part. In this example, the team was invited by the indigenous community, and there were long-
established relationships and trust, all laying solid groundwork for development. There had been a needs assessment of the community’s priorities and training geared accordingly. Indigenous leadership is involved, ongoing expatriate partnership and change is slowly happening. As I witnessed during our time in Peru, assessments of needs, approach to change, belief systems, balance of costs/benefits, and expectations for change can vary widely depending on culture and perspective. From my experience and other examples around the world, it seems the most lasting, sustainable changes are forged through committed relationships in an invested, involved community, with shared resources, all guided by local leadership … and a lot of patience with the process. Listening, asking questions, communicating takes time. A lot of time. And in our hurried, outcomes-based, resultsdriven world (and profession), we are often unwilling to employ the proverbial ‘tincture of time’ as it might pertain to health, development and change. Change is happening with my jungle friends – but very slowly. One CHW at a time. My hope is that by examining these matters, we might serve well, share our resources and knowledge appropriately, and be respectful of the doors (or lack thereof) we find before us - even those right here at home.
The Ten Seed Technique is a modified Participatory Learning and Action (PLA) tool. It was introduced by Dr Ravi Jayakaran as a tool that can enable illiterate community members to participate in the discussions about their community’s needs. See http://www.csd-i.org/ten-seed-technique-fieldnote/ i
An excellent book called Toxic Charity by Robert Lupton has recently shaped my thinking on the issue of free care in settings other than emergency/crisis. It’s more focused on social services than medical, but there are definitely many applicable principles. Along similar lines, but much more focused on economic development is a book called Dead Aid by Dambisa Moyo. ii
The American Journal of Medicine, Vol 125, No 6, June 2012
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Resident Highlight John Alpern, M.D. Delivering healthcare to immigrants and refugees can be both challenging and rewarding. It demands a base level of interest in another’s culture and language, becoming familiar with diseases that are often unfamiliar, and having to John Alpern, M.D. navigate particular challenges, such as using an interpreter while juggling time constraints. When we looked at the literature, we found that there has been little data published on trainees’ attitudes, knowledge, and experience with immigrants and refugees. We decided to explore this further and have created a survey of residents at the University of Minnesota in various fields that explores positive and negative experiences working with this population and various factors that may play into these views. These data will help to design educational interventions that may improve the care we give this vulnerable population.
health. As Kate Venable stressed in her recent TTMS lecture (please see www.globalhealth.umn.edu/education/ travel-and-tropical-medicine-series/index.htm), health care and its delivery are contextual, and I have been trying to figure out ways to prepare to do no harm in the setting of a truly exciting yet very much unknown clinical situation. My first move was to case my bookshelf. Two books that I read over the summer were particularly helpful in this regard: The Practice of International Health, A Case-Based Orientation, edited by Daniel Perlman and Ananya Roy, and A Guide for Global Health Workers, Building Partnerships in the Americas, edited by Margo J. Krasnoff. Three common themes emerged. The first is an emphasis on relationships as the primary strength of any community health project. The second is an element of humility and a willingness to admit failures and to learn from them. A third is the importance of doing everything that one can to find common ground with partners, an example being doing as much as one as one can to speak the same language.
It is this third theme of language that frightens me the most. I have always envied polyglots, and have seen the ability to speak several languages as the mix of a bit of magic and superior brainpower. I am trying, in preparation for an upcoming elective, to learn a bit of a new language. I began with audio CDs to listen to while driving. Driving, however, is a challenge at baseline and the addition of instructions to “listen and repeat” make the experience almost treacherous. Books are helping a tiny bit, and the assurance by my st UMN preceptor that there will be interpreters available on On September 21 , an orientation was held for those the wards is also calming. residents scheduled to take My second move was to case the websites and information an elective rotation abroad. available through the UMN Global Health Pathway and Faculty members included Global Health Track. Both contain site-specific information Mike Pitt, Tina Slusher, Cin- and general information about getting the most out of an dy Howard, and Jen international elective rotation. McEntee. The day started with introductions, included My third move has been to case my contacts. Hearing about Calla Brown, M.D. information about prehow other residents have prepared and the way that the travel readiness, culture, health and safety, and concluded faculty members at the orientation practice self-care while with a simulation exercise, part of a project entitled abroad was very inspiring. Also, as I will be traveling with “Simulation Use for Global Away Rotations (S.U.G.A.R., for three other residents and a faculty preceptor, we met tomore information please see www.globalpeds.umn/ gether to discuss the specific hospital site, goals, and expecResearch/S.U.G.A.R./index.htm).” During this activity, four tations. This allowed me to plan what I need to bring with residents were tasked with a neonatal resuscitation that me and what pediatric and medicine topics I should read was complicated by a nuchal cord and prolonged bradycar- about ahead of time. I have also been lucky enough to chat dia. During the post-simulation reflection the group diswith one of the staff members of my continuity clinic site cussed working with available resources, communication of who has traveled to the hospital were our group will be roimportant medical information in an emotionally charged tating. Finally, I called an old friend from Ecuador, one of my situation, and how the outcome of the simulation affected former host brothers. His advice was almost perfectly simeach of the participants and attendees. ple: “Be humble, and don’t be rude. Also, send a letter to
Calla Brown, M.D.
The day got me thinking about preparation for the unknown your husband every once in a while when you are there.” His counsel reminded me of one of the most important in general, and also more specifically about the role of a parts of preparation that was stressed in the orientation— relatively inexperienced trainee in the context of global Continued to next page 9
Continued from previous page having a strong support system and making sure that the support system is a part of the rotation experience as well.
Beth Thielen, M.D. Among individuals traveling in the developing world, visiting friends and relatives (VFR) travelers have historically been a population with relatively high rates of travel-associated illness and low utilization of pre-travel medical services. Improved Beth Thielen, M.D. access to pre-travel services may help to reduce travel-associated morbidity and mortality, but for many VFR travelers, there are significant barriers to accessing these services, including knowledge, geographic, financial, language and cultural barriers. We
Intern Spotlight Martha Montgomery My name is Martha Montgomery, I am one of the new categorical medicine interns this year. I am interested in epidemiology, tropical medicine, and outbreak investigation. In the spring of 2008 I was working in an epidemiology branch at one of the instiMartha Montgomery tutes of the NIH. I was almost two years out of graduate school for public health where I had focused on international health epidemiology, and I was aching to change back to an international focus. The previous fall I had discovered that Doctors without Borders (MSF) was hiring epidemiologists. Somehow or another I managed to navigate the online application process followed by an interview in New York. MSF was seeking an epidemiologist to help in the investigation of a measles outbreak in Niger in West Africa. The outbreak had been identified in January and the vaccination campaign was already underway, but they needed an epidemiologist to help estimate the coverage rate of the vaccination campaign. Because it was an emergency assignment I had to decide to accept the position on short notice. Within a few days I had suspended my job at the NIH, packed my
hypothesized that uptake of pre-travel medical services could be improved by creat ing a "traveling travel clinic" to provide culturally competent and affordable travel services within the communities at greatest need for these services. To pilot this model, we created a clinic specifically for individuals traveling to Saudi Arabia for Hajj. To overcome barriers to access, we partnered with a clinic site in a predominantly East African neighborhood and offered walk-in appointments and reduced rates. All clinics were staffed by trained interpreters and providers with specific interest in global health, many of whom were University of Minnesota medical students and residents. Clinics were extensively publicized both at community events and through travel agents coordinating Hajj trips. In future years, we hope to expand awareness of this service within the community, potentially partnering with other providers of travel services to reach larger numbers of patients. We also hope that our experiences with this clinic will provide a model for expanding pre-travel services to other populations of disenfranchised travelers. bags, and was on a plane to New York for new volunteer field training. I had a few days of training in New York before I was on a plane for Geneva, Switzerland where I was supposed to be briefed on my assignment. My briefing involved one static-filled phone conversation with someone loosely aware of the outbreak and who happened to be in Kenya. And voila. I was on my way. I arrived in Niamey, the capital of Niger a couple of days later. I was suddenly immersed exclusively in French, a language that I had only studied for a couple of semesters in college. The first person I met at the airport introduced himself to me, “Hello, I am Christof. You may not know me [and, to be sure, I didn’t] I am the MSF international president.” Woops. The next day I made the 6 hour drive to Zinder, followed the next day by another drive out to our work site in Magaria, a rural town just north of Nigeria. Magaria in April is at the end of the dry season. There are only two seasons in Niger- wet and dry. The temperature during the days was invariably over 104 degrees. With the haze from the heat, the sand blended with vacant skies to create a rather monotonous background for the six weeks that I was there. The team was already half-way through the emergency vaccination campaign. By the end of the campaign they would vaccinate 286,915 children for measles. Our team consisted of one head of mission, two doctors, five nurses and a couple of logisticians plus over one hundred national staff who were hired temporarily to assist with the campaign. My role as the team epidemiologist was to complete a rapid Continued to next page 10
assessment of the coverage rate of the campaign to determine what percent of children had been vaccinated. When I finally arrived, apparently no one had informed them of my arrival. They told me that they were expecting me a few days earlier, and when I didn’t show they assumed I wasn’t coming. Needless to say I was on my own in terms of planning since they weren’t sure what to do with me. Fortunately Ihad great assistance from a mentor based in Geneva; however, our only method of communication was an infrequent conversation via satellite telephone. I received instructions on how to conduct a randomized survey (walk to the center of the village, spin a pen, and start walking), then designed the survey forms, hired teams to conduct the surveys, and trained them (in French!) to conduct the surveys. We had 5 teams of two people each. Overall we interviewed 1131 children from approximately 300 families. From this we determined that the overall coverage rate of the campaign was around 80%.There were innumerable obstacles to the work itself, not least of which was my inexperience with outbreak investigations and the multiple language barriers. There were also more medically relevant challenges. One day we happened upon a family who had walked several hours to seek care for several of their children who had developed measles. They were initially reluctant to seek care until two of the siblings died of their illness. With no clinical experience at the time I felt at a loss for how to clinically assess to the situation. I was grateful for and completely reliant on the knowledge of the national staff nurses with us who quickly assessed the severity of illness and offered treatment (though at that time all we had to offer was some acetaminophen). My first few months of intern year have been stressful and enjoyable in ways similar to my time in Niger, although thankfully the communication methods are (usually) more reliable. I have had language barriers (Epic and CPRS). I have again been reliant on mentors and nurses to lead me through the sudden barrage of autonomy. And I have been especially grateful for my fellow residents and interns who have guided me through the first few months.
Matt Goers Hi, my name is Matthew Goers and I’m a new intern in the University of Minnesota Internal Medicine Residency. A little about me, I grew up and went to school in Missouri, but spent a large portion of my childhood traveling with my parMatt Goers ents. Since I was twelve, I’ve gotten the chance to follow my mother to Kenya, Cuba and
Jamaica for much of her medical work. I obviously didn’t understand at the time what certain health problems were and what poverty really was, however I do remember two particular situations in Kenya that I still carry with me. One experience was traveling to a Masai community, and meeting 20-30 other children before school started. We spent a couple hours playing soccer and just being silly little kids, and I still have one of the photographs of all of us. I’m obviously very visible being the only mzungu present, but otherwise you probably couldn’t tell I had just met these children. That would be my first experience in what I’d come to call solidarity. I obviously took a lot away from that situation, and the picture of all of us together is still sitting on my shelf at home. Now, the second memory I have is less enjoyable, but it’s just as teachable. I remember being in the crowded traffic of Nairobi and a cachectic appearing child with yellowing eyes, my age, knocking on the passenger window with an outstretched hand. I was confused because, being just a kid myself, I had no money. But I quickly found out that being mzungu meant a lot more than just being “white.” Now, that being my first immersion in seeing what a real wealth and health disparity looked like, it obviously was very different than my fun filled morning with the Masai children. That contrast never sat well with me even at that time, and to this day I’m trying to reconcile those two images. Years later, these early experiences lead me to pursue a career in medicine. During medical school I had very limited time to travel, but there was one organization that gave me my reason for working in global health. GlobeMed was an organization comprised of university students that partnered with grassroots clinics in developing nations. Our partner was in Bushenyi, Uganda and primarily was focused on serving the local HIV/AIDS community. Our role was to build up the community’s public health infrastructure, establishing microfinance programs for livestock and farms to improve nutrition as well as a well digging project around the clinic. These obviously achieved real, tangible outcomes. Over the past 4 years, we saw improvements in pediatric growth charts and income from livestock reinvested into children’s education. But there was something more to this group than the results we achieved. On the one hand I had always seen the existence of health disparities as a sort of an injustice, so working with our partners in Bushenyi made sense to me. But at the same time I never wanted to be paternal or make this work into charity and just keep adding to the same mindset of two different worlds. I didn’t want to be a mzungu, but I did want to be a partner. And so I realized through this group that solidarity can be a tool against injustice, and I believe wholeheartedly that it is an effective and necessary path towards health equity in our time. 11
L e s s
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M o r e By Kristina Krohn, M.D.
Eradicating small pox, or fighting HIV, defined generations of doctors. No one knows for sure what will define the medical lives of the next generation of Global Health providers, but they may just change American medicine.
Kristina Krohn, M.D.
Global Health physicians from the generation called Millennials grew up exposed to a medical world almost unimaginable just a few decades ago. People in the United States have practically lost the ability to die with dignity, as elegantly stated by Allen Frances in “Too Much Medicine is Bad For Your Health” (Huffington Post, September 13, 2013), while people around the world, include here, still cannot access even basic care.
This newsletter if full of young physicians training between these two worlds: ready to jump on a plane to investigate measles outbreaks in Niger (Dr. Montgomery), or translate lessons learned in the Peace Corps to caring for the underserved in our own backyards (Dr. Brown). It is that latter experience that I want to address. Physicians exposed to both worlds, the world with too many tests, and the world with too few, will need to step up and lead the way through the next evolution in American medicine. Providing quality medical care is not the same as providing large quantities of medical care. Our current fee-for-service system financially rewards quantity over quality. Providers’ morals remained the only defense for quality care. While most providers want to give quality care, the system has not supported us in doing so. In the transition to pay-forperformance, we are left questioning, which tests are really valuable and which cause more harm than good? Who better to determine which tests are needed and which can be discarded than providers who trained with all the possible blood draws and imaging in the world, but choose to practice medicine in locales where they must do without? Forty years after “Where There is No Doctor” revolutionized access to health education in remote areas, it is time we bring those same lessons home. I for one am looking forward to joining our new Global Health Chief, Dr. Abassi and the rest of my generation as we join the fight to guarantee quality health care to all, even here in the United States.
Director’s note: In 2012, Kristina Krohn, MD, Medicine-Pediatrics PGY3 completed a very competitive one year Global Health and the Media Fellowship, co-sponsored by Stanford University and NBC News. We are thrilled she will be a regular contributor to the newsletter.
August 22, 2013 Global Health Social Hour Michael Taylor, Magdalena Kappelman, Amy Borden, Brian Muthyala
Emily Moody, Benjamin Katz, Junaid Niqzi, Tina Slusher 12
Mentorship Program Launches Fall 2013 Formalized mentoring is a key component of career development for residents in the global health pathway. All residents and faculty affiliated with the global health pathway are expected to participate. Mentoring is meant both to facilitate support for residents as they consider career pathways in global health and ensure that residents are progressing in meeting expectations of the pathway. The leadership for the mentoring program is faculty member Mike Westerhaus and the Global Health Chief Resident. Requirements All residents in the global health pathway are expected to identify at least one global health faculty member as their mentor. All faculty affiliated with the global health pathway are expected to serve as mentors for up to 2-3 residents in the pathway. Mentees should meet with their mentor at least two times per academic year. Ideally, these meetings should happen in person, but can take place through skype, facetime, phone, etc. Residents are required to log these meetings in RMS (details Dec. 2013). How to Find a Mentor All residents who completed the on-line interest survey will receive the names of 2-4 potential faculty mentors and their contact information. Suggested mentors were chosen based on a rough matching of your interests with those of faculty. Do not read any further into the suggested mentors – this step is just meant to help get you started. You are not required to restrict yourself to the suggested mentors. If you know of another faculty member who you would like to have mentor you, reach out to that person. If you already have a mentor in the global health pathway, you’re set. There is no need to find someone else.
Residents should contact potential mentors by November and set up an initial meeting before the end of the calendar year. If you’d like to set up initial meetings with a couple of faculty in order to decide, feel free to do that. You should then choose the faculty member who will best mentor you. There will be no hard feelings if you have an initial meeting with a mentor and then decide to go with someone else. Your mentor doesn’t have to be someone in your planned specialty or geographic area of interest. Once you have chosen your mentor, please notify either Mike Westerhaus or the chief resident so we can record it. How to use my Mentor Mentors should help you think about your career pathway. Ask mentors how they got where they did, what challenges they faced along the way, what worked well, etc. Mentors can also be helpful in thinking about how a career in global health blends with personal life Mentors should help you ask the right questions and may not always have the right answers. Mentors can help you troubleshoot logistics in the global health pathway. Some mentors might be able to help you find funding sources for particular projects, conferences, opportunities, etc. Mentors might be people that you ask for letters of recommendation in the future. Mentors may encourage you to continue moving forward in meeting the requirements of the pathway. Contact Mike Westerhaus or the global health chief resident if you are having trouble making a connection. Please complete the on-line survey and you will be provided with the names of a few potential mentors.
Michael Rhodes, Kristina Schultz, Anteneh Zewde
Global Health
Calla Brown, Hope Pogemiller, Zach Kaltenborn, Annette Bloush, Annette Bloush, Pat Walker, David Aarti Bhatt, Beth Thielen Boulware, Jennifer McEntee 13
Tropical and Travel Medicine Seminars
#UOFMTTMS
Since 1999, the Tropical and Travel Medicine Seminars (#UOFMTTMS) have been a tradition, reflecting our core value of providing medical education in the global village. Seminars are held monthly through June 2014 on the 3rd Wednesday of the month from 6pm - 8pm at the Twin Cities Shriners Hospitals for Children®.
Upcoming Seminars: November 20, 2013, December 18, 2013, January 15, 2013 Past presentations are available for viewing on our website. Dr. Kate Venable presents at the Sept. 18 Tropical and Travel Seminar.
First-of-its-kind Specialty Module From Online Global health Course We're happy to announce the launch of the first specialtyspecific online learning module produced in partnership with Department of Family Medicine and Community Health. This new course offering, available in early October, features a 40-hour curriculum targeted to family physicians and other primary care providers who plan to practice in international settings with limited sources. The module is comprised of content from the soon-to-be released 2013 Online Global Health Course. CME credits will be available. More information can be found at z.umn.edu/ globalhealthcourse (select Specialty Series in Family medicine under Specialized Offerings). Please help us spread the word about this exciting new offering with your colleagues in family medicine.
Snapshot of Moodle Site
Department of Medicine
Global Health Oct obe r 2 013
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