* VOLUME 8 * ISSUE 3 * December 2014
Department of Medicine
Global Health MEDICAL EDUCATION IN THE GLOBAL VILLAGE
A publication of the Global Health Pathway, engaged in medical education, clinical care and research in global health. Battling Ebola in Sierra Leone continued on page 12 Faculty Spotlight… page 2 The Story of Anton… page 3 Intern Spotlight page 5 Resident Spotlight page 6 U of M Hosts… page 8 The Fight for Equal… page 9 Global Health Expands… page 11 ASTMH page 16
Battling Ebola in Sierra Leone by Malini DeSilva, MD, MPH
Editor’s Note: Dr. DeSilva is a 2012 Graduate of the Global Health Pathway
As a CDC Epidemic Intelligence Service (EIS) officer, I had the opportunity to travel to Sierra Leone to take part in the CDC’s Ebola Response. I’m fairly sure everyone involved in the Ebola response can agree on some key interventions for containment of the outbreak: comprehensive case and contact finding, effective medical management of patients, community engagement, and strict adherence to infection prevention practices. continued on page 12
Global Health Footprint “Where in the World Are We Working?” The goal of the Global Health Footprint, launched to the continued on page 12 public on November 1, is to provide viewers with a snapshot of the breadth and depth of the work our faculty and residents are engaged in locally and worldwide. Each footprint outlines the summary of the project, key contact, collaborators, partner organizations, and the project’s contact information.
Find the Global Health Footprint by visiting the Global Health website at: www.globalhealth.umn.edu 1
Faculty Spotlight by Jonathan Kirsch, MD
Patricia Walker, MD, DTM&H, CTropMed®, FASTMH Department of Medicine, Associate Professor Medicine Global Health, Director William Stauffer, MD, MPH, CTropMed® Department of Medicine, Associate Professor Medicine Global Health Course, Director Brett Hendel-Paterson, MD, CTropMed® Department of Medicine, Assistant Professor Medicine Global Health Online Course, Director Not pictured: Kate Venable, MD, CTropMed® Department of Medicine, Assistant Professor Medicine Global Health Online Course, CoDirector David Boulware, MD, CTropMed® Department of Medicine, Associate Professor Global Health Research
Director’s Note Patricia Walker, MD, DTM&H, CTropMed®, FASTMH
2014 has been a banner year for the Global Health Pathway. We have 47 residents currently enrolled – 20 in Internal Medicine, 24 in MedicinePediatrics, and 3 in Medicine Dermatology. Residents in the Pathway participate in our annual spring inperson Global Health Course (one of only 18 in the world), our online Global Health Course, evening Tropical and Travel Medicine Seminar Series, and international electives for two months at one of 13 sites. In addition, they have the option of a local rotation at HealthPartners Travel and Tropical Medicine Center, as well as opportunity for a Global Health Chief Resident year. continued on page 14
Having attended medical school here at the University of Minnesota, I’m happy to be back after 11 years away from this great state. I’m especially excited to be part of the Global Health Pathway, a major factor in my return to the U of M. Back in medical school, I was the co-chair of the Student’s International Health Committee, sat on the board of the Center for Cross-Cultural Health, and volunteered at La Clinica (West Side Community Clinic) in St. Paul. During my training, I participated in clinical and human rights work for one year in Chiapas, Mexico. After internal medicine residency at HCMC, I moved to Ithaca, New York where I worked in hospital medicine, primary care, eventually landing the coolest job in the world. In this latter position, I traveled throughout the state of NY with a mobile medical unit (my rusty VW wagon) and a coordinator, providing medical services to migrant farmworkers in old farmhouses, trailers, dairy barns, apple orchards, vineyards, and anywhere else I was needed. I now join the Global Health Pathway core faculty after working at the University of North Carolina for six years, focusing on hospital medicine and volunteering in global health and migrant farmworker health. Global health is not simply about treating people abroad. It also includes understanding why people migrate locally, leaving behind family, and taking risks as they adapt to new environments. I’ve cared for Latino patients in MN, NY, NC and Mexico, and I believe that care for underserved, marginalized populations doesn’t stop at artificial borders. I’ve been a member of the board of Doctors for Global Health for six years and hope to apply some of their social justice principles in my work here. continued on page 5
Jonathan Kirsch, MD removing an ingrown toenail in the kitchen of a trailer on a dairy farm.
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Our family likes to travel whenever we can, grow and prepare food, bike, ski, hike, and listen to and play music. I am a year round bike commuter, and our family is excited to be back in Minnesota so we can enjoy the great outdoors, especially when there is a lot of snow.
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The Story of Anton—Hennepin’s Year in Review by Ron Johannsen, MD Editor’s Note: Dr. Johannsen directs the Global Health Pathway at Hennepin County Medical Center in Minneapolis, MN
My HCMC Global Health Pathway resident, Manoj Ray, was just one week into his international rotation with me here in the central highlands of Madagascar at the Anseribe Hospital, a 150 bed facility that serves a population that makes the equivalent of $2 US per day, when I met up with him as he was running across the hospital courtyard on one warm evening. Dr. Ray was carrying a limp four year old named Anton, and was accompanied by the Malagasy Nurse holding an oxygen tank that was connected to a mask over the child’s face. A quick report and assessment delivered in the moonlight of this hospital compound revealed that Anton had been admitted 36 hours previously with severe recurrent asthma. He had been making progress until he suddenly deteriorated 30 minutes previously. His oxygen saturation was in the 50’s, respiratory rate was 40-50, and pulses were faint and barely palpable. This facility had never intubated a patient on the wards, so the patient was receiving intermittent support with bag ventilation. My resident was rushing the patient to X-ray when I informed him that X-ray facilities at this hospital are available routinely during the day and only by call-in at night. It would take perhaps as long as one hour to get a tech on site. We re-routed the patient to the Block (operating room) where our nurse anesthetist was fortunately working late and intubated the child. A used portable ultrasound machine that we had previously brought to this hospital was quickly utilized to try to identify a sliding lung sign in the right upper and left upper anterior thorax. The absence of a sliding lung sign, confirming our percussion findings, allowed us to confidently diagnose tension pneumothorax on the right. There were no small chest tubes available, but cutting side holes in a pediatric nasogastric tube served us well as a chest tube. The intensive care unit nurse traveling with us (my wife, Colleen) and the Malagasy nurse anesthetist, collectively jerry-rigged a system of partially fluid-filled bottles to act as a water seal for the chest tube. Anton showed significant improvement in vitals
over the next 15 minutes, but he needed a higher level of care than was available on the wards. Over the next three days, until Anton recovered enough to go on general ward care, my resident resourcefully worked out a 1:1 nursing ratio with a moonlighting system. With hospital permission, he provided a $5 payment for each 8-hour moonlighting nursing shift (an economic opportunity that led to many volunteers). Our accompanying American intensive care nurse used it as an opportunity to train the revolving nursing staff in higher level care management.
Anton, 24 hours after treatment of his tension pneumothorax, with his mother and moonlighting Malagasy nurse. Picture was taken with permission for teaching purposes.
This is one example of the many opportunities during an international rotation where a global health resident can resourcefully manage patient care in resource-limited areas and work creatively with local staff to learn from each other as they manage such patients. This case alone led to great enthusiasm by the Malagasy physician staff to learn emergency ultrasound techniques. It also prompted discussions by the Malagasy hospital team to begin plans for a step-up unit for critically ill patients and specialized training for nurses manning such units as well as development of a rapid response nursing team for acutely deteriorating patients on the wards. The demographics of patients managed in resource-limited intensive care units in the developing world represent younger patients with more curable conditions in contrast to older patients with more chronic disease that we see in the western world intensive care units. continued on page 4
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As director of Global Health at Hennepin County Medical Center, it has been my pleasure to work with our IM and EM/IM Global Health Pathway residents. During calendar year 2014, HCMC resident participants in international health rotations have included: Dr. Adam Kolb (currently our Global Health Chief Resident) at Kalra hospital in India, Dr. Ricky Dhaliwal at Selian Hospital in Tanzania, Dr. Rachael Krob at Nazarene Hospital in Papua New Guinea, Dr. Johanna Bischof at Mahosot Hospital in Laos, and Dr. Marco Salman at Mfangano Island Health Center in Kenya. At HCMC we have also started offering an international rotation for our Cardiology Fellowship Program. Dr. Louis Kohl worked at Mabingo and Banzo hospitals with me on a secondary rheumatic heart disease research project, and Dr. Ankur Kalra participated in a one month international rotation at AIMS Hospital in New Delhi, India. His experience along with an accompanying editorial by the past president of the American College of Cardiology will be published in the Journal of the American College of Cardiology in December of this year.
Dr. Rachael Krob, HCMC EM/IM resident, evaluating an infant in Papa, New Guinea with failure to thrive. Picture was taken with permission for teaching purposes.
Dr. Adam Kolb, seated and wearing the blue shirt, on his international rotation at Kalra Hospital in India with ICU staff members where he focused his project on teaching bedside ultrasound in critically ill patients.
A junior staff member is using ultrasound to place a central line. Prior to Adam Kolb’s visit, central lines were placed by anatomic landmarks. Dr. Kolb is the Global Health Pathway Chief Resident at HCMC.
HCMC/ANW Cardiology fellow, Louis Kohl, Dr. Ron Johannsen and Cameroonian Pediatric Physician Assistant, Vera, assessing CVP by imaging the IVC to adjust hydration prior to chemotherapy induction in a young Burkett's Lymphoma patient. With this pre-hydration approach, we have reduced the 28% tumor lysis syndrome 30 day mortality to near 0%. Results soon to be published and incorporated into standard practice at multiple sites in sub-Saharan Africa.
New additions to our global health family at Hennepin County Medical Center include Dr. Rosemary Quirk, the new director of the HCMC Internal Medicine Residency Training Program. She has a diploma in tropical medicine from the University of Liverpool, England, and in the recent past has set up a residency program at Mahosot Hospital in Laos. Dr. Rachel Sandler also joined our staff this year. She has special interest and experience with immigrant health and will work with us to set up a site in Peru as well as coordinate our monthly global health morning reports with our residency program. Dr. Steve Dunlop continues with his overseas activities in Tanzania and has been an important champion in bringing portable ultrasound skills to overseas sites and training our residents who participate in international rotations to further disseminate this important skill set in the developing world. continued on page 6
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My global health focus at the University of Minnesota, outside of hospital medicine, is in Migrant Health. I am working in a multi-disciplinary collaboration with other faculty to create a Migrant Health rotation which I hope to have approved and available by the summer of 2015. Initially for residents in internal medicine and medicine-pediatrics, I hope to offer this rotation to medical, dental, and public health students as well as those in other disciplines. During this first year, I will collaborate with community-engaged partner organizations and work to establish trust with the migrant farmworker population, that is very marginalized, and traditionally very difficult to access due to fears of immigration. The rotation will include readings, online learning, and video instruction to teach the social determinants of health for migrant and seasonal farmworkers in addition to clinical care in a mobile health unit and, hopefully, experiential learning alongside farmworkers. I will also be collaborating with colleagues in other departments to create a needs assessment or resource map to better understand the needs of the migrant and seasonal farmworkers in Minnesota.
Intern Spotlight by Darin Ruanpeng, MD Internal Medicine, PGY-1
Western medicine became popular in Thailand 120 years ago when a group of American missionaries arrived. Not long after that, King Chulalongkorn founded and subsidized the first public hospital and medical school. When Prince Mahidol returned back from the United States after studying medicine, he asked the Rockefeller Foundation for assistance with the Thai medical and education system. Since that time, Thailand has continued to train people and develop a health care system. As medicine advances, young Thai physicians continue to obtain advanced training in Europe, Japan, and America, to remain current and help deliver the best care possible to 67 million people in the country and nearby. I am a board certified internist in Thailand, and I worked for the Research Institute for Health Sciences at Chiang Mai University for 2 years (2012-2014) in multi-center clinical trials in the field of HIV as a research physician. The HPTN 052, iPrEx OLE, and Encorel trials have been published, and the START, 1077HS, SECOND-LINE, and A5279 trials are still ongoing. I am also working on an anal cancer screening for men who have sex with men in Thailand. I came to Minnesota to further my internal medicine training. Being away from home and training abroad provides magnificent opportunities to learn and grow. Working at three hospitals and at Health Partners Center for International Health (CIH), I experience different systems that I might bring back to improve patient care in Thailand. One particular thing from the CIH that triggers my interest is immigrant health. Thailand has more than one million working immigrants from Myanmar, Laos, and Cambodia. Now these people pay about 80 US dollars per year with about one dollar co-pay for health insurance from the Ministry of Public Health, which covers most, but not all health problems. Extrapolating immigrant health benefits here to those in Thailand, a middle-income country, will be challenging. 5
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Dr. Hernando Gonzales is the Costa Rica site director for our residents and University of Minnesota residents. We are in the process of further formalizing our relationships with Kalra and Duncan Hospitals in India, Mbingo, and Banso Hospitals in Cameroon, Tenwick, and Kajabi Hospitals in Kenya and Germania Hospital in Upper Egypt. HCMC Global Health Pathway alumnus, Dr. David Vandyke, currently a Hospitalist in Wisconsin, continues yearly trips to Mbingo Hospital in Cameroon where he helped establish and continues to support an Internal Medicine training program. Quality graduate medical education is an exception in many resource-limited counties. HCMC Global Health Pathway alumnus, Dr. Manoj Ray, now an Infectious Disease specialist in Minneapolis, is working with me to develop cost effective microbiology laboratory services in hospitals in Kenya and Madagascar. This will lead to overall cost savings, mortality reduction, and good antibiotic stewardship at these sites.
Dr. Lou Kohl and Colleen Johannsen, RN running an echo based secondary prevention Rheumatic Heart Disease screening program at a school in NW Cameroon (RHD). This study is evaluating a single view with color doppler versus multiple echo views to screen for asymptomatic RHD. When screening thousands of children in a district the amount of necessary imaging time is critical. Data supporting the single view method will be published soon. Pictures of patients were taken with permission for teaching purposes.
The story of Anton, our child in Madagascar, goes well beyond preserving one important life. This international collaboration matures in a unique way as our global health residents make a difference in the world around them, teaching and learning from their colleagues overseas. Lessons learned during these rotations are applied locally especially with the immigrant population that we all serve in the Twin Cities.
Resident Spotlight by Anteneh Zewde, MD Internal Medicine, PGY-2
Ethiopian farming
Anteneh with King Holmes, ID researcher from the University of Washington, Seattle
Returning to Ethiopia to do a one month research project was not only a continuation of my commitment in fighting infectious disease, but also a return to my past. Asella Hospital is where my mom delivered my brother and where I was admitted for “Nefase” (“wind,” or pneumonia) as a young child. As an Ethiopian trained physician, now with the experience of one year of residency in the United States, returning home brought mixed feelings. continued on page 7
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My research project is focused on cryptococcal meningitis, with Dr. David Boulware as my mentor. I spent one month setting up the groundwork for this operational research project. We studied the practicality and clinical outcomes of using fluconazole prophylaxis for patients with positive serum cryptococcal antigens. It was challenging to make logistics of a research project a reality in a setting without electronic medical records. We established ways of providing continuity of care and research follow-up that were appropriate in that setting.
Anteneh working on Cryptococcal research project with colleagues in Ethiopia (Tafese Tufa, microbiologist with white shirt, Dr. Abera Balcha, internist with gray sweater).
I also participated in clinical and teaching activities at the hospital. I rounded with interns and presented a few morning reports. I taught medical students and led an Advanced Life Support Class for interns. Most of the clinical medicine was very familiar to me since I completed medical school and internship in Ethiopia. However, I now have a completely different system to compare it to. At times I felt helpless; I had to sit through a patient dying due to lack of an oxygen cylinder, while knowing that patients in the U.S. could compare mask choices. I have treated tuberculosis in the US, wearing my N95 mask, with patients placed in negative pressure isolation rooms. In Asella, there were far more active pulmonary TB patients sharing an open space, often next to another patient who was immunosuppressed. Patients seldom finish their anti-TB therapy and are lost to follow-up. It is often not known if we are dealing with MDR/XMDR, which contributes to a huge public health issue globally. If we talk about health as a human right, from what I have seen, we are very early in the fight. Infectious diseases do not respect boundaries. We need to find a sustainable way of making global health care standardized, instead of acting only in times of crisis. When I was training in Ethiopia, I was aware of these gaps in our medical system. We read Harrison’s and knew what ideal treatment was, but didn’t necessarily have it available. With the perspective of having participated in the US medical system for one year, the differences are more clear and more painful. Not only are resources lacking, but the infrastructure is broken. Doctors training there leave in part because they know medicine but cannot practice it as it should be done. This is an injustice; the underprivileged deserve more. I feel strongly that I need to give back to my country and reverse the brain drain. Through clinical work and operational research, I will do this in my future. It is an obligation for me to do so, as I become part of the privileged from the unprivileged. As people, we are morally obligated to make an effort towards sharing. My grandmother used to say, “You will not get buried with your wealth, but people will always talk about your greed, so learn to share.” ---When we move beyond sentiments to action, we of course incur risks, and these deter many. But it is possible, clearly, to link lofty ideals to sound analysis.--- from Pathologies of Power by Paul Farmer
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U of M Hosts Third Humanitarian Crisis Simulation Course by Bridget Scott
The University of Minnesota hosted its third Humanitarian Crisis Simulation Course the weekend of September 5-7, 2014 at Phillippo Scout Camp in Cannon Falls, Minnesota. The simulation is one of a handful of such programs in North America that brings together students and academics with humanitarian practitioners to provide hands-on training in a life-like humanitarian situation. The Department of Medicine Global Health, School of Public Health, and Hubert H. Humphrey School of Public Affairs co-hosted the simulation that included 48 students and more than 150 volunteers during the 48-hour experience. It was designed to immerse students in an environment that resembled a typical humanitarian crisis.
The goal of the simulation was to equip students with the knowledge and skills necessary to respond to humanitarian crises and to address a variety of emergencies with large populations in distress. The course started with an intensive first day of training on the fundamentals of humanitarian aid. Students learned by working in small groups where discussions and hands-on learning took place. Minnesota National Guard strategizing at the Simulation Course. Photo credit Bridget Scott
Participants collaborate at the Humanitarian Crisis Simulation Course. Photo credit Bridget Scott
Course director, Sarah Kesler, MD, CTropMed速, is an assistant professor in the Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine at the University of Minnesota. Coteacher, Eric James, PhD, is the executive director of FieldReady and has worked for over 15 years with humanitarian emergencies. Co-teacher, William Stauffer, III, MD, MSPH, CTropMed速, is an associate professor in the Department of Medicine at the University of Minnesota and serves as the director for the Department of Medicine Global Health Course as well as medical/technical expert for the Division of Global Migration and Quarantine for the CDC. He has worked extensively overseas in clinical medicine as well as public health.
The core of the weekend was the simulation itself, an opportunity for participants to respond as if they were facing an actual humanitarian crisis. Participants were then divided into emergency response teams and immersed in the simulated crisis area. The crisis involved a large population living in an unstable border area with very poor infrastructure. Team members worked together to apply the skills and knowledge acquired during the first day of training to assess and respond to the crisis. The goal of the participants was to develop a plan that addressed the various problems of the region, including malnutrition, poor infrastructure, insecurity, and the violation of human rights. continued on page 11
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The Fight for Equal Rights Varies Around the World by Kristina Krohn, MD Editor’s Note: Dr. Krohn is a 4th year Medicine-Pediatrics resident and has completed a one year Global Health and Media Fellowship co-sponsored by Stanford University and NBC News.
Time magazine included "feminism" as a possible word to ban in the New Year (see their poll http://time.com/3576870/worst-words-poll-2014/ for words to remove from the English language due to over use, other words include “literally” and “om nom nom nom”). I think it is still underused and too few people are practicing the ideas of feminism. Yeah, totally underused, when 18.3% of American women are raped according the Centers for Disease Control and Prevention. I do not mean slept with a boyfriend or date and regretted it. I mean forced against her will, beaten, drugged, or threatened - raped. I think this statistic is horrifying. In this day and age, it should be horrifying that any woman or child is raped. There are safer places in the world than the United States, but there are more dangerous places as well. For example, 71% of Ethiopian women report being raped by a stranger or being raped or beaten by their partner, according to the World Health Organization. Over 7 months after “Our Girls” in Nigeria were kidnapped from their school, the girls are still missing. Stolen from their families. Boko Haram leaders now say they "married them off a long time ago," according to National Public Radio (NPR). NPR also reports that the group continues to abduct young women. Even after a so-called cease-fire in late October, they invaded a town, killed 4 men and abducted 60 women. While Boko Haram leaders says “married,” sold as property or slaves is probably a more accurate description. I don't want to picture what these "marriages" are like. You don't have to go back very far into the past in any country, before most women had no rights in a marriage. No property rights. No rights to their children in a divorce. No rights to a divorce. No right to say no to "performing duties of marriage.” continued on page 14
Tropical & Travel Medicine Seminars
Since 1999, the Tropical & 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 May 2015 on the 3rd Wednesday of each month from 6pm-8pm at the Twin Cities Shriners Hospitals for Children. Upcoming Seminars: December 17: SocMed, Dr. Michael Westerhaus January 21: HCMC EM, Dr. Steve Dunlop February 18: UMN Pediatrics March 18: UMN Center for Global Health & Social Responsibility April 15: TBD May 20: TBD *Recordings of past presentations available on our website Ryan Fabrizius, MD, presents the Nov Global Health Update at TTMS
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U of M Global Health Chief Resident’s Corner by Hope Pogemiller, MD, MPH This year has been a fantastic whirlwind of increasing structure in the U of M Global Health Pathway, with overwhelming resident interest in global health. We are introducing education about working with an medical interpreter into the curriculum, and we have had monthly Balint Group meetings with Georgi Kroupin, PhD to talk about tricky patient interactions at Health Partners Center for International Health. Global health topics covered in morning report have been well-received, with residents including global health diagnoses in the differentials and considering collections of symptoms, areas of endemicity for particular diagnoses, and unique exposure risks. Faculty, residents, and alumni have been published and are active in the American Society of Tropical Medicine & Hygiene. We had many residents travel to take the ASTMH exam in New Orleans, and a large group was able to stay for the 4 day conference (see ASTMH section on page 15). The recruitment season has been filled with Internal Medicine and Med/Peds Interviewees interested in global health. Residents will be matched with mentors soon, the International Rotation Applications are due in early December, and information about each of the U of M’s Partner Sites is now on the Global Health webpage with a short site description and a few slides of explanation. Members of the U of M can find detailed information about each of our Partner Sites in Google+, with video presentations explaining details for each location. It’s an exciting time to be in the realm of global health at the U of M. Click on icon to view our facebook account.
Click on icon to view our twitter account..
UMN faculty and residents who would like to join our google +community, please email Hope Pogemiller (poge0008@umn.edu)
Department of Medicine
Global Health December 2014 Published by Medicine Global Health, Department of Medicine, University of Minnesota To find out how you can make a difference, please contact: Russell Betts, Development Officer 612-626-4569 or rbetts@umn.edu www.globalhealth.umn.edu Click here to donate The University of Minnesota is an equal opportunity educator and employer Copyright 2014 University of Minnesota All rights reserved The University of Minnesota respects the privacy of all individuals. We do not and will not have access to your medical records. We will not sell, trade, or exchange your name or mailing address with outside organizations. You may request at any time that we remove your name from our mailing list. If you have questions about our privacy policy, visit http://privacy.umn.edu/mass-email/ 10
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More than 150 volunteers supported the event via instructing and role-playing capacities throughout the weekend. Volunteers included the Minnesota National Guard, the University of Minnesota, and a number of additional universities including Case Western, the New School, the University of Manitoba, and the Mayo Clinic. Numerous individuals from non-profit organizations were also involved, including professionals with experience at the UN, WHO, International Crisis Group, American Refugee Committee, New American Alliance for Development, and other groups. Volunteers were fully committed to their assignments and created a lifelike experience for students. This unique dynamic pushed the learners to enter into the simulation without hesitation and to work collaboratively to come up with solutions for the problems they were faced in real time. The simulation introduced and highlighted the knowledge, standards, and best practices in Humanitarian Aid. It allowed participants the opportunity to apply acquired skills in a realistic setting utilizing collaboration and teamwork to respond quickly to a crisis. The Humanitarian Crisis Simulation Course offered students the opportunity to experience and navigate humanitarian crisis management in a hands-on environment.
Global Health Expands Instructional Design Position by Shawn Haag, BS
This year I joined the Department of Medicine (DOM) as the instructional designer for Global Health. In this role, I primarily provide instructional design and project management support for Global Health courses and the Pathway. I also provide other management and project support for DOM Education projects. I was previously with the Center for Transportation Studies at the University of Minnesota, where I provided project management and curriculum development support. I have a bachelor of science degree from the University of Minnesota, and I am one semester away from completing my master of education in learning technologies degree, also from the University of Minnesota. I am an avid Gopher football and basketball fan, and I enjoy spending time with my wife, Nina, and our goldendoodle, Teddie.
Shawn, Nina, and Teddie at Vadnais Lake, in Vadnais Heights, MN.
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However, over the course of the month I was deployed, I observed a constant struggle to implement what in theory seemed so simple. And I’ve spent a great deal of time since I returned trying to think about why. Sierra Leone is made up of 14 districts, and each district is subdivided into chiefdoms made up of sections, which include multiple villages. When I arrived in Africa I found out I was assigned to a “roving team” consisting of three people: an epidemiologist, an infection prevention and control (IPC) specialist (me), and our driver. My role was to provide technical advice and training in IPC; I would not be providing any direct patient care. The plan was for our small team to perform assessments of districts where CDC had not yet established itself. During the last two weeks of my trip, our team traveled throughout Koinadugu, the northernmost district in the country and the last district to report a confirmed Ebola case.
Left: Malini with her driver Suma using chlorinated water to wash hands Right: Malini with Tim, her roving team partner.
Koinadugu has some of the worst roads in the country – it took us more than 4 hours to travel the 50 miles from the district capital to one village – and extremely limited cell phone coverage – villagers would often have to travel 1 to 2 miles or more to a hilltop to find a cellular signal. These logistical hurdles meant that routine surveillance activities were either not taking place or only to a very minimal extent. Because of the district’s location along the Guinean border and the high burden of disease in neighboring districts, it was very suspicious that Koinadugu did not have any Ebola cases almost five months into Sierra Leone’s outbreak. However, by mid-October, rumors of Ebola cases in one of the southern chiefdoms reached the district medical team who sent surveillance team members to investigate the situation. The first three confirmed Ebola cases in Koinadugu were reported on October 20, all from the same chiefdom. In the three weeks that followed, case counts grew almost exponentially, overwhelming an already taxed and inadequate medical system. There were no Ebola Treatment Units (ETUs) in Koinadugu, and the nearest facilities for dedicated Ebola care were at least 5 hours away. Initially, suspect cases were first brought to a holding center in the district’s capital (a 4-5 hour, hot, jarring ambulance ride from their village) and if positive, patients would then be transferred to an ETU another 4-5 hours away. However, these long journeys were often too taxing for those who had suspected cases, some of whom died en route. To decrease transit times, WHO started construction of a community care center in a village with a large number of reported cases. While awaiting completion of the center, they used an old school building as a temporary facility to isolate suspect patients. The care team did all they could with their severely limited resources to try and keep people alive as safely as possible until test results confirmed a patient’s status and arrangements were made for transport to a treatment facility if necessary. The district medical team stationed case investigators, burial teams, lab teams, and ambulances in the same village, an attempt to improve case management and surveillance activities. But, the workload was too much for the small number of staff available and rather than get ahead of the curve, they were doing all they could to keep up with the ever growing current case investigation and burial needs. continued on page 13
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Things were far from perfect: at times there was not enough oral rehydration solution (ORS) at the care center, lab teams were not readily available to draw blood so patients stayed at the temporary facility longer than necessary while waiting for test results to tell them their fate, contact tracing was slow and far from exhaustive, and we frequently identified breaches in personal protective equipment (PPE). The response teams were in constant need of supplies – case investigation forms, PPE, basic oral medications, etc. And, local response teams were tired; they didn’t have the luxury of leaving after a month, this would be their dayto-day reality for the foreseeable future.
outbreak has been complicated at best and is a constantly evolving process. I remain hopeful that the situation on the ground will improve and with growing international support, increased manpower, and sustained commitment of the local communities the response teams will be able to beat the disease. However, none of these things are guaranteed and in the absence of these resources the future of this outbreak and stability of Western Africa remains uncertain.
Figuring out the logistics of implementing control interventions for this unprecedented
Roads around Koinadugu
Global Health Research Update by David Boulware, MD, CTropMed® Nate Bahr, Global Health Pathway alumnus and current ID fellow, has published a recent manuscript on the “Methods of Rapid Diagnosis for the Etiology of Meningitis in Adults” in the October 2014 issue of Biomarkers in Medicine. Available at: dx.doi.org/10.2217/bmm.14.67 New ID faculty -- Radha Rajasingham, UMN IMER alumnus, in collaboration with Global Health course participants Abdu Musubire (2014) and Henry Nabeta (2013) have a manuscript on the “Epidemiology of Meningitis in an HIV-Infected Ugandan Cohort” published in the November issue of the American Journal of Tropical Medical Hygiene. In this study, cryptococcal meningitis accounted for 60% of meningitis in adults in Uganda. Available at: dx.doi.org/10.4269/ajtmh.14-0452 continued on page 15
Global Health Chief Resident Announcement The Global Health Pathway is pleased to announce that we have chosen Global Health Chief Residents for 2016-2017. Matt Goers and Aarti Bhatt will be Internal Medicine Global Health Chief Residents, after Sheiphali Gandhi and Ryan Fabrizius during the 2015-2016 academic year.
Sheiphali Gandhi PGY3, Ryan Fabrizius PGY4, Aarti Bhatt PGY3, and Matt Goers PGY2 13
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Even in “enlightened” places, the remnants of centuries of devaluing women can be seen everywhere; decreased pay, decreased promotions and the characterization of successful women as unlikeable are just a few examples. #HeForShe with Emma Watson specifically invites men to participate more in equal rights for women around the world. Lean In by Sheryl Sandberg encourages women to be more involved at the world place in order to not be discounted. So no, I don't think feminism is an overused word. I think this is a sad push back against more people speaking up for women all over the world. Human rights should include all humans. They are something women and men should continue to fight for. However, there are reasons feminism was placed in this list of potentially bannable words. First, suggesting a change to the status quo always has some backlash. Second, feminism has a bad reputation in the eyes of many young people. Feminists have been portrayed in the media as man haters for a long time. The word puts many men and women on the defensive. Some suggest that it is better, and more effective, to talk about equality rather than feminism. Cathy Young, a writer for Time, suggested that feminism was a “First World Problem”. I could not disagree more. Arguing about the meaning of the word, sure, but the root of the problem – devaluing people due to their sex is not a first world problem. It is a world problem. I hope that the discussion about the use of the word feminism is because people are finding their voices and are moving from words to deeds. Now is the time to move beyond the hashtags and really bring back our girls. Provide access to education for all. Equal pay for equal work. Equal opportunities for maternity and paternity leave. Equal opportunities to stay home with a family. When men can stay home and care for children, all children around the world can have access to an education, all people have access to work, everyone feels safe and has control of his/her own body, and every parent receives respect for caring for a family, then, maybe, the word feminism may be over used. But not until then. Editor’s Note: Time Magazine has now apologized on their website for including the word feminist in a list of words to ban. continued from page 2
The creation of a Global Health Chief Resident position in 2013 has been a major positive addition to the pathway, supporting the early global health career goals of the Chief, as well as serving as a major resource for residents and faculty. After our successful global health graduation and research symposium this May, we have 85 full graduates of our Pathway, all of whom have completed all the requirements to sit for the ASTMH Certifying Exam in Clinical Tropical Medicine and Travelers Health. In fact, this year the University of Minnesota prepared the most candidates world-wide to sit for this exam, a testament to our commitment to preparing the next generation of clinicians, educators and researchers in global health. We sponsor the price of membership in ASTMH for residents and have 17 resident members. Global Health faculty have key leadership positions in ASTMH nationally and three are Fellows of the Society. This year the faculty approved a mission vision and values statement, (see box on page 15), as well as core values for our international rotations. We have worked to be true to those values all year, as you will read in our year end newsletter. In addition, faculty have had a busy year lecturing locally and nationally, publishing case reports, and contributing an UpToDate article on immigrant health as well as commentaries in key journals and research findings. continued on page 15
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New faculty members this year include Mark Jacobson, Kate Venable, and Jonathan Kirsch. We added three new international sites: SocMed Northern Uganda, (Mike Westerhaus), Haiti (Ben Trappey), and Nepal (Chhabilal Sharma). To help us keep track of all of our activities, Ann Fandrey and I designed and implemented a “Where in the world are we?” map featured on our website, which in 2015 will be used as a model for tracking Academic Health Center wide global health activities. I would like to end this year with an inspiring example of the incredible resident physicians we have in the Pathway. Dr. Jon Alpern (GH 2013 graduate), Dr. Bill Stauffer, and Dr. Aaron Kesselheim published a commentary in NEJM in November, 2014 which speaks to the high price of generic drugs, such as albendazole, and their impact on the global community. Their commentary received a great deal of press nationally, and reflects the best outcome we can have as a Pathway: graduates with a set of core values in global health, who combine scholarly activities and passion to help improve health worldwide. Many thanks to all those who contribute their time, energy, and expertise to our work in medical education in the global village, and best wishes in 2015.
Global Health Pathway, Department of Medicine, University of Minnesota Mission We are committed to improving the health of individuals and communities globally.
Vision
We are engaged in global health teaching, research, and clinical care which is values based and which improves the health of individuals and communities in Minnesota and the world.
Values
We value compassion, excellence, and equity for all, with a focus on the disenfranchised.
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Joshua Rhein, Nate Bahr, and colleagues from Uganda and South Africa have written a manuscript on “Detection of High Cerebrospinal Fluid Levels of (1→3)-β-d-Glucan in Cryptococcal Meningitis” in the fall issue of the Open Forum Infectious Disease reporting that the dogma that beta-d-glucan is not detected in Cryptococcus is incorrect. Higher levels of beta-D-glucan in CSF were independently associated with increased mortality in persons with cryptococcal meningitis. Available at: dx.doi.org/10.1093/ofid/ofu105 Henry Nabeta, Nate Bahr, Nicholas Fossland, Steve Dunlop, and colleagues have published on the “Accuracy of Noninvasive Intraocular Pressure or Optic Nerve Sheath Diameter Measurements for Predicting Elevated Intracranial Pressure in Cryptococcal Meningitis” in Open Forum Infectious Diseases. Available at: dx.doi.org/10.1093/ofid/ofu093 15
ASTMH November 2014 in New Orleans, LA 47 of 129 people worldwide who took the ASTMH exam on November 1st were graduates from our UMN/CDC Live Global Health Course!
Above left: Dr. Nate Bahr, ID Fellow at UMN, presenting about his cryptococcal meningitis research Above right: Dr. Pat Walker continues to serve on the ASTMH Council (Board of Directors) and had the opportunity to meet with Bill Gates with other council members at the annual meeting
Left: Dr. Jim Wallace, PGY3 presenting a case vignette poster Right: Dr. Hope Pogemiller’s case vignette poster Left: Dr. Brett HendelPaterson presenting a session about travel medicine Middle: Bill Gates delivering keynote speech Right: U of M Residents enjoying New Orleans Jazz
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