v7 i3 Exploring Collaborations for Health Education and Research

VO LU M E 7

ISSUE 3

SUMMER 2014

Department of Medicine

Global Health

Medical Education in the Global Village

A publication of the Global H e a l t h P a t h w a y, e n g a g e d i n medical education, clinical

Exploring Collaborations for Health Education and Research University of Minnesota and Chiang Mai University Working Trip to Myanmar

care and research in global health.

Photo courtesy of Dr. Walker

By Patricia F. Walker, MD, DTM&H, FASTMH Global Health Pathway Associate Program Director Exploring Collaborations for Health Education and Research Patricia F. Walker, MD, DTM&H, FASTMH Continued on Page 4 Faculty Feature Elizabeth A. Rogers, MD, MAS Page 2 Alumni Spotlight Malini DeSilva, MD, MPH Noah Goldfarb, MD and Jon Alpern, MD Page 6

In early February, a multi-disciplinary

related needs in Myanmar are extensive,

delegation from the University of Minnesota

and as the country is opening up, leaders at

(UMN) and Chiang Mai University (CMU)

the Ministry of Health and Universities are

in Thailand completed a productive and

interested in exploring collaborations.

exciting one week exploratory trip initiating a UMN and CMU One Health, One Science, One World collaboration with Myanmar.

The delegation was co-lead by Dr. Patricia Walker, UMN Department of Medicine, and

Is It Working?

by Kristina Krohn, MD Page 12

Dr. Deborah Olson, UMN School of Public

Resident Highlight Brian Hilliard, MD and Magdalena A. Kappelman, DO Page 13

in the Academic Health Center, as well as

Events/Announcements Page 14-19

page 7 highlighting delegates.) Health-

Health. Representatives from all schools the OďŹƒce of Global Programs and Strategy

Prior to the trip, the University conducted extensive background research and identiďŹ ed three key goals for the trip: to hear from colleagues in Myanmar their priority areas of need, and potential joint educational and research opportunities to address them; to identify potential colleagues for collaborative work; and, to identify next steps in our collaboration.

(GPS Alliance) and CMU participated. (See Collaborations continued on page 4

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D i r e c t o r ’s N o t e

Faculty Feature Elizabeth A. Rogers, MD, MAS Assistant Professor, General Internal Medicine and Pediatrics, University of Minnesota

Medical school gives us the tools we need to make diagnoses and 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

provide medical treatments, but clinical training and practice, including experiences abroad, have taught me about the vast array of

Spring brings graduation every year and this

causes for those illnesses that fall

year we were excited to hold the inaugural

far beyond what our medical tools

Global Health Graduation and Research

can fix.

Symposium at the beautiful Weisman Art

I think I was beginning to catch

Museum. We partnered with our colleagues

glimpses of this but couldn’t yet

in Global Pediatrics to highlight program

put it into coherent thoughts and

successes for the year.

words during my first years of

We thanked Mahsa Abassi, DO for serving

medical school at the University

as an outstanding first Global Health Chief.

of Nebraska. The patients in

In addition, thirteen posters were presented

the student-run clinic who were

At a national global health

and judged, and the following residents

uninsured and had delayed

conference at the end of my

received awards for their work:

accessing care, those who didn’t

second year, I heard the then-

• Outstanding Achievement Award

speak English and had difficulty

president of a small, grass-roots

for Global Health Scholarship and

finding resources, the patients who

nonprofit called Doctors for Global

Humanitarianism: Jonathan Alpern, MD

returned without improvement

Health (DGH, www.dghonline.org)

despite intensification of treatment

speak. She spoke about her time

plans – all left me with a nagging

in the rural village of Estancia,

unease that I couldn’t quite put my

El Salvador, where her intention

finger on. I then spent a summer in

to spend 3 months turned into a

1st Place: Katie Anderson, MD

Central America – a month with my

15-month stint. She spoke about

2nd Place: Paul Wratkowski, MD

university’s program in Guatemala

the organization’s mission of

3rd Place: Danielle Brueck, MD

followed by a month in Nicaragua

“community accompaniment,” or

3rd Place: Emily Hall, MD

working on a research project –

working side-by-side with members

A full listing of the graduates and photos are

where the social and environmental

of the partner community and

listed pages 16 and 17.

factors that influence health were

simply being there to share risk

impossible to overlook. I was

and responsibility, to respond to

• Excellence in Teaching Award: Michael Westerhaus, MD • Excellence in Global Health Research

We wish them all the best in their careers in medicine and global health!

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Elizabeth A. Rogers, MD, MAS

desire to truly learn the language and continue to learn from these experiences. I jumped into leadership roles with my school’s global health group and waited for the next opportunities to return to Latin America.

hooked, perhaps some by the sense invitations and opportunities,and of urgency that the medical setting

to commit over the long-term in

carried in those places, but also by

partnering with the community. For

the gorgeous culture and a

the first time, these concepts Continued to Next Page

Left To Right: Leslie Harlson, Annie Baxter, and Elizabeth Rogers hiking in New Zealand

Rogers

Left To Right: Med-Peds Reseidency Classmates Neil Gupta, Christiane Haeffele, Matthew Lewis and Elizabeth Rogers

Continued From Previous Page

made sense, further linking health and medicine and social

painful pasts, the diversity of knowledge that went far

justice. And her talk very much stuck with me into my third

beyond my own initial perceptions, and the sadness of saying

year, helping to propel my decision to take a year after that

goodbyes. My perspective across all aspects of life would be

to spend abroad and focus on international health. And to

forever shifted.

finally improve my Spanish to use-able levels! I was accepted as a DGH volunteer and after a few months of more structured programs in Nicaragua and Ecuador, left to spend 6 months in the rural village of Santa Marta, El Salvador, with DGH.

After medical school, I pursued a residency in Internal Medicine and Pediatrics in Boston, being drawn to the program because of it’s potential for supporting continued global health pursuits, and with the intention of focusing ultimately in primary care. Experiences clinically with the

It turns out that year has been one of the most influential

Indian Health Service in Chinle, Arizona; with a needs

of my life. Not only did I get to work with a local physician

assessment of and teaching community health workers

in the community clinic helping to diagnose common and

in a group in northern Guatemala; and with a quality

uncommon things, I got to learn how their community health

improvement project in a hospital in Santo Domingo,

worker continued to function with incredible capacity

Dominican Republic; solidified a desire to also consider how

after nearly two decades of experience; and how the

to incorporate into my career a focus on the larger social,

community had built their educational system year-by-year

environmental, and systems-level issues that influence

and grade-by-grade until it was finally being incorporated

health. I continued on to a research fellowship at the

into the ministry of education’s programming; and how a

University of California, San Francisco, with the intention

local group of youth, armed with some knowledge gained

of learning solid research skills that could give credibility to

from international resources and a solid mentor, were

advocating for new strategies to improve our systems for the

educating young adolescents about reproductive health and

underserved. I worked clinically with a diverse population

supporting imprisoned men in stretching their stereotypes of

at the county hospital clinics and pursued research projects

gender roles. I experienced the most gracious and generous

focU.S.ed on new models of better supporting patients

hospitality I’d ever received, and moments of loneliness in a

from health disparities populations in diabetes management

foreign place that I’d not yet felt. I learned the importance

and prevention. In addition, being a board member of DGH

of taking the time to first listen, the weightiness of decisions

for the past 7 years has gifted me with the opportunity to

made by families that have no good option and that I would

continue thinking about how the organization is carrying out

never have to make, the joys of simply showing up and being

its mission to truly “accompany” its partner communities on

present together, the humor that so many managed despite

the ground, how to fairly and responsibility allocate Continued on Page 9

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Photo courtesy of Dr. Walker

Collaborations Continued From Page 1

In brief, the University of Minnesota hopes to expand an existing knowledge network of partnered schools and colleges in Thailand, Vietnam, Malaysia, and Indonesia engaged with the University of Minnesota to include institutions of higher education in the health sciences of Myanmar, with the goal of furthering capacity building using a One Health One Science One World approach.

Colleagues in Myanmar were very receptive to our visit, and explained that what distinguishes us from other U.S. universities is the partnership with Chiang Mai University as

The delegation then traveled north for two days of meetings with Ministry of Health (MOH) officials in the new capital of Nye Pi Taw. The Myanmar Ministry of Health is based in Nay Pyi Taw, 200 miles (320km) north of the old capital Yangon and 160 miles south of Mandalay. It is divided into 7 departments, each led by a director general: Health, Health Planning, Medical Sciences, Medical Research (2 departments, for Lower Myanmar and Upper Myanmar) and Traditional Medicine. There are 9 divisions underneath the Department of Health led by 9 directors: Administration, Planning, Public Health, Medical Care, Disease Control, Food and Drug Administration, National Health Laboratory, Occupational Health and Nursing.

a flagship Southeast Asian University, our One Health/trans-

Delegates met with the Minister of Health, Dr. Pe Thet

disciplinary focus, and Chiang Mai-Minnesota-Myanmar

Khin, who has voiced the need for increased funding, well-

similarities based on service to large rural populations.

trained health professionals, and improved health facilities.

The delegation met with USAID staff in Yangon. USAID is a key potential funding source and partner in Myanmar.

USAID ceased operations in Myanmar for approximately twenty years as part of sanctions imposed on the military regime. The current mission was launched in November 2012

In addition, they met with the Director General (DG) of the Department of Medical Science, Dr. Than Zaw Myint and many others. Delegation members had the opportunity to make presentations about each of their respective schools at Chiang Mai University and at the University of Minnesota.

upon President Obama’s visit after Myanmar President Thein

The MOH, not Ministry of Education, is responsible for all

Sein and the government began its reforms. The USAID

health professions education nationally, with the exception

Myanmar mission’s overall focus is humanitarian assistance

of veterinary medicine, which is under the Ministry of

and health. The mission’s approach and twenty years ofU.S.

Livestock, Fisheries, & Rural Development. Minister Khin

sanctions have precluded it from fully engaging with the

insightfully has an Assistant Director General in each of the

Myanmar government since reopening the mission; USAID is

9 ministries “because they all impact health” (Agriculture,

monitoring how the transition is unfolding, and the strategy

Forestry, Industry, etc). He gave an example of children

will be impacted by 2015 elections.

being malnourished if livestock is not healthy, reflecting an

4 Continued to Next Page

Collaborations Continued from previous page

appreciation of the One Health concept and approach. The

Course is offered at a developing country rate to Myanmar,

Minister is interested in support for health system reform,

and discussions have occurred about holding a tropical

health professions education reform, and research. The

medicine short course in Yangon, with Myanmar faculty

Minister and Director General have a history of and interest

providing expertise and teaching. Colleagues in Myanmar

in international engagement, including relationships with

are very interested in research collaborations and technical

private universities, and expressed interest in visiting the

assistance to upgrade lab facilities, as well as consultations

University of Minnesota.

on health infrastructure, policy , accreditation, and

However, University of Minnesota delegates are not waiting for full funding to strengthen our ties with our new colleagues in Myanmar. Dr Karlyn Eckman, who has

quality improvement. There is also interest in a potential pilot project, based on Health Partners’ Cooperative Development work in Uganda, focusing on rural hospitals.

been working on tropical forestry in the region for years,

The potential for a major University of Minnesota and

continues to expand her networks on the Myanmar-India

Chiang Mai University commitment to working and

border. Colleagues in Veterinary Medicine, Dentistry and

collaborating with Myanmar, via a One Health, One Science,

Pharmacy are making connections. The School of Public

One World collaboration, is very exciting – stay tuned for

Health is interested in potentially involving Myanmar

more information!

colleagues with the iMPH at Chiang Mai University, among other potential collaborations. The Dept. of Medicine was

Next steps:

pleased to sponsor two physicians from Myanmar, Drs Pora

A new University of Minnesota Global Programs & Strategy

Sar and Thyraroat Sou to attend the Asian Clinical Tropical

Alliance (GPSA) and Center for Global Health and Social

Medicine course in Bangkok in July, 2014. In addition,

Responsibility (CGHSR) effort to establish a process

colleagues in Minnesota and Myanmar have expressed an

for UMN-wide affiliation agreements will help lay the

interest in holding a one week faculty development seminar

groundwork for an MOU with Chiang Mai University and

in Myanmar, with a focus on best practices in medical

the Ministry of Health in Myanmar. In addition, a diverse a

education and teaching. The DOM Global Health Online

CGHSR planning committee is submitting a proposal letter for USAID consideration in preparation for a full grant proposal, as well as researching other funding opportunities for joint efforts in Myanmar.

Photos of exploratory visit to Myanmar with members of the University of Minnesota Academic Health Center, the College of Food, Agriculture, and Natural Sciences, and the Associate Vice-President and Dean of International Programs as well as colleagues from Chiang Mai University, Thailand

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Challenges to Achieving Health in Myanmar as outlined by the Minister of Health and his staff:

• Rural recruitment and retention: how to bring in rural students and incentivize them to return to rural area.

• Reform of the educational sector and healthcare, as called for by their President, Dr Thein Sein. The need to modify and align our philosophy/thinking and system with a rapidly changing world and challenges.

• The need for basic infrastructure and improvement.

• An acute shortage of competent and qualified workforce.

There are 64,000 villages, and leaders say every village must have a qualified health provider, but universities are not training nearly enough to meet this goal.

• Need for international partnerships. “We cannot stand

and healthcare system reform: Myanmar is developing a human resources development plan in concert with WHO, with long-term goal of universal health coverage.

• Need for specialties and additional training: 1) for clinicians: Myanmar has 38 doctoral programs

alone,” we were told. Professionals lack contact with

in different specialties—graduates are confident in theory

outside world and need exposure for University students

and practice but “need extra training and international

and faculty to improve quality of education. The DG

exposure”, in both primary and tertiary care, as well as in

emphasized that Myanmar also has a lot to share with and

specialties (surgeons, pediatrics, oncologists)

provide to international partners.

• Disease Burden. Rising trend of non-communicable

2) for midwives and nurses: MOH has 46 nursing/ midwifery programs (2 years and 3 years, respectively).

diseases: diabetes, heart disease, dental caries; infectious

Midwives are frontrunners in health system—especially for

disease such as AIDS/HIV, TB, & malaria, including multi-

UNDP goals and MCH priorities. Health is the primary

drug resistant tuberculosis and malaria.

target for improving the rural status or rural communities

• Lack of research culture in universities.

• Recruiting a younger generation of health sciences faculty with interest and expertise in education.

6

• Health reform will focus on capacity building in health

overall, and it is essential to create high number of quality midwives. For nursing, they expressed the need for critical care, oncology, and other specialties, including Master’s and diploma programs.

6 Photos courtesy of Dr. Walker

Collaboration Delegation Continued From Page 1

University of Minnesota Delegates:

Boynton Health Center • Saghar Shafizadeh, MD, MPH, Internal Medicine and

Center for Global Health & Social Responsibility • Delegation Co-Leader: Debra K. Olson, DNP, MPH, Professor and Associate Dean, School of Public Health; Academic Health Center, Executive Director, Center for Global Health and Social Responsibility

Pediatrics University Partnership for Health Informatics: • Andrew F. Nelson, MPH, Adjunct Professor, and Executive Director, HealthPartners Institute for Education and Research

• UMN Coordinator: Andrea B. Hickle, MPH, Associate Director

Myanmar Coordinator: • Khin Aye Htwe, MBBS, D.Obst, M.Med.Sc. (Ob/Gyn),

Medical School

retired physician

• Delegation Co-Leader: Patricia F. Walker, MD, DTM&H, Associate Program Director, Global Health Pathway, and Associate Professor, Division of Infectious Disease & International Medicine

Chiang Mai University Delegates: CMU President’s Office: • Dr. Thanaruk Suwanprapisa, CMU Vice President

College of Pharmacy • Julie K. Johnson, PharmD, Associate Dean for Professional and External Relations, and Associate Professor, Pharmaceutical Care and Health Systems

CMU Faculty of Medicine: • Dr. Siwaporn Chankrachang, Associate Professor and Dean Consultant in Foreign Affairs • Ms. Sasiwimol Singhanetr, RN, MBA, acting visit secretary

School of Public Health

for Medicine group

• Debra Olson (see above for detail under Center for Global Health & Social Responsibility)

CMU Faculty of Veterinary Medicine: • Dr. Khwanchai Kreausukon, Assistant Professor and

School of Dentistry

Director of Veterinary Public Health

• Karin Quick, DDS, PhD, Associate Professor and Director, Division of Dental Public Health, Department of Primary Dental Care College of Veterinary Medicine • John Deen, DVM, MS, PhD, Diplomate of ABVP and ACAW, Professor of Epidemiology College of Food, Agriculture and Natural Resource Sciences • Karlyn Eckman, PhD, MS, MA, Senior Research Associate, Department of Forest Resources Global Programs & Strategy Alliance • Meredith M. McQuaid, JD, Associate Vice President and Dean of International Programs 7

Alumni Spotlight Malini DeSilva, MD, MPH

Dr. Malini DeSilva

Field Epidemic Intelligence Service Officer Centers for Disease Control and Prevention Oregon Health Authority

After I completed my Med-Peds residency last June, I decided to take a break from clinical medicine to become an Epidemic Intelligence Service (EIS) officer. EIS is a two-year postgraduate training program in applied epidemiology run by the Centers for Disease Control and Prevention. Like almost all the classes before us, my class started our two years taking a one-month biostatistics and epidemiology course in Atlanta. Because EIS officers come from diverse backgrounds the program tries to ensure everyone has a basic understanding of epi and biostats before sending us to our respective programs. I was fortunate to be placed at the Oregon Public Health Department.

After summer course finished, I flew back to Minnesota and the following day began my 30-hour road trip to the Pacific Northwest. On Friday, August 2 while in Idaho, I received a call from one of the senior communicable disease epidemiologists in Oregon, Bill Keene.

calls with CDC teams, local health departments, drinking water services, and public relations specialists discussing environmental testing results, public health interventions, and epidemiologic methods. At some point, it was decided that to better characterize the epidemiology of the outbreak and assess the overall attack rate, I would lead a door-to-door investigation in Baker City. And, with the help and support of an amazing team of co-workers and new friends, we spent 5 days surveying over 200 randomly sampled households. After analyzing the data, the weighted community attack rate for this outbreak was almost 30%!

Once I got through those first three weeks, things slowed down. I spent more time at my computer entering and analyzing data and I started epi on-call training. As the state communicable disease epi on-call, we receive calls from

“This is as good as it gets!” he exclaimed when I answered

local health departments, other state health departments,

the phone. He continued to tell me about what appeared to

medical providers, and local citizens about anything

be a community-wide Cryptosporidium outbreak in Baker

communicable disease related for which questions arise.

City, a small town in eastern Oregon. “We’re here [Baker

After two weeks of training, I now only have to take call a

City] and I think you should just come meet us tomorrow.

couple of times each month. I’ve received tons of questions

No stopping in Portland first. You’re going to start working

about rabies – bats seem to as plentiful in Oregon as

before you even step foot in the office. This is going to be a

mosquitoes are in Minnesota, and other well known diseases

great story!”

like pertussis, norovirus, and measles.

Unfortunately, I didn’t make it to Baker City until two weeks

My medical training has definitely come in handy for things

later as my road trip companion needed to catch a plane out

like this, but there always seems to be some sort of twist and

of Portland the following day. But, that call was the start of

I’m constantly reading investigative guidelines and consulting

a whirlwind first month for which our summer course hadn’t

other people about questions that arise.

quite prepared me.

The following weeks were spent in countless conference 8

Most recently, I’ve been working on a syphilis case-control study. Similar to many other cities around the country, Continued to Next Page

Linda and Patrick Rogers with Elizabeth Rogers overlooking San Francisco

Rogers

colleagues, residents, and medical students. I’m still early

Continued From Page 3

on this long path that is a medical career, but already I’ve

resources, and where to seek sources of funding that are truly ethical. Through this, I’ve gotten to work with some of the most inspiring and wise people I know.

Today, as a new faculty member at the University of Minnesota, I get to combine caring for a diverse and largely immigrant patient population at CUHCC clinic in one-on-one interactions with doing research and considering systemlevel improvements to help mitigate disparities. Though clinically and in research my attention has shifted toward domestic issues in more recent years, the opportunity to live and work in a city teaming with immigrant diversity feels exciting, as does the potential to learn from and collaborate with a substantial number of impressive and inspiring

learned so much, and despite the disparities that continue to plague our patients and communities here and across the globe, I feel hopeful.

In these reflective moments, I return to what Dr. Jack Geiger said during his keynote address at the 2002 DGH General Assembly: “What we are really saying to the people we work with is that their lives are as worthy as our own; that their lives are as worthy of a life as everyone else’s; that all life is equally valuable. And what we, by our presence and our work, demonstrate is a commitment to the idea of equity, not as an abstraction, but as something that has to do immediately and directly with the lives of the people we work with.”

DeSilva Continued from previoius page

about the experiences of my other classmates who have

Oregon has seen a tremendous increase in early syphilis

worked on the Elk River chemical spill in West Virginia,

cases over the last 5 years. To try and evaluate for novel

serogroup B meningococcal outbreaks at UC Santa Barbara

risk factors associated with infection, we decided that a

and Princeton, sudden cardiac death associated with Lyme

traditional case-control study might be able to help answer

carditis, or the current Ebola outbreak in west Africa.

some questions. After almost three months of interviews, I’m still recruiting control participants, but hope to complete the study soon and then finish data analysis.

Similar to my residency, I’ve been fortunate to have knowledgeable, good-humored, experienced mentors to guide me along the way and am excited to see what the

I could never have anticipated the projects I’ve worked on or

next year brings. Hopefully I’ll find a way to help with an

lessons I’ve learned in the last 10 months. I also can’t speak

international project.

9

Noah Goldfarb, M.D. Internal Medicine - Dermatology, Academic Practice

also got the opportunity to see many of Costa Rica’s most beautiful natural attractions including el Arenal Volcano/ Tabacón Hot Springs and Manuel Antonio national park. In

When I first arrived, Marino, a friendly taxi driver, greeted me at the airport. He drove me to the house where I would then stay for the next three months in Costa Rica. I lived with a very kind and warm-hearted, retired couple that only spoke Spanish and lived in the downtown area

addition to having the experience of a lifetime, I also made lifelong colleagues and friends, who I am currently working with to set-up an international grand rounds web conference to connect the dermatology departments at the University of Minnesota and El Hospital Rafael Ángel Calderón Guardia.

of San Jose. Prior to my trip I spoke no Spanish, so for the first several weeks, communicating with people was very difficult. The experience, including my host family, language school and clinical dermatology mentors were organized by the Universidad de Ciencias Medicas (UCIMED) through the help of Dr. Hernando Gonzalez, in the division of Gastroenterology at Hennepin County Medical Center, facilitated by the Global Health Pathway in the internal medicine residency program at the University of Minnesota.

Every morning, I attended a four-hour private Spanish lesson

Noah Goldfarb, M.D.

Jon Alpern, M.D.

at the ILISA Language Institute, where I focused on medical Spanish. Over lunch, from 12-1:00 pm, I attended Latin dance

A Closer View

lessons, including salsa and bachata, organized by ILISA.

Jon Alpern, M.D.

In the afternoons, I worked at El Hospital Rafael Ángel Calderón Guardia, one of the public hospitals in San Jose,

Chief Resident, Regions Hospital, St. Paul, MN

where I saw and helped manage many complex dermatology

The walk from the house to Selian Hospital took me along

patients. We saw incredible cases from cutaneous larva

a hilly back road, about 8 km in total. Potholes, children

migrans and cutaneous tuberculosis to leprosy and several

in packs on their way to school, men speeding on their

cases of leishmaniasis. This was an invaluable experience,

motorcycles, the rule. The back face of Mt. Meru towers

to see and manage diseases that most residents only get the

over a stretch of the road adjacent to a cornfield. The

opportunity to read about in textbooks. I also spent one

walk is far more enjoyable than the drive. There are a few

afternoon each week doing wound care for complex medical

steep inclines to conquer on the way in, the same ones

wounds and one afternoon with a private dermatologist

done gracefully by some Masai women who do so while

at Clinica Biblica, a private hospital in San Jose. At the

balancing heavy buckets of water over their heads, wearing

private practice site, I learned about cosmetic dermatology

sandals. One hour later, I would arrive at Selian Hospital

for patients with skin of color, advanced wound healing

to catch the end of the chapel service, enjoy Chai with the

technology, not yet available in the United States, as well as

other registrars and interns, and begin rounds. I spent just

how to use in vivo confocal microscopy, a new technology for

under two months in Arusha, Tanzania volunteering as a third

diagnosing skin cancers, not widely accessible in the U.S. By

year medical resident. I decided to go into medicine largely

the end of my three months, I was able to communicate and

as a result of my experiences internationally, and this trip

obtain a complete history from my only Spanish speaking

was another opportunity to determine if and how I would

patients and felt much more comfortable managing complex

practice medicine abroad or at the minimum, in a resource-

wounds and patients with tropical infectious skin diseases. I

poor setting. When I reflect on my time in Arusha, I am

10

Alpern

Continued From Previous Page

Perhaps even more than in the hospital, my impression of reminded of those Georgas Seura paintings. He painted

the local Tanzanians also became more complicated the

using the technique called Pointillism, creating images using

deeper the relationship. In general, I found Tanzanians to

dots. From far away, the images in the paintings are easy to

be extremely welcoming and friendly to me. No matter

see, but up close sometimes all you can see are the dots.

where I would walk, I would be greeted with a friendly smile.

These paintings are more complicated up close. In the

One day while walking around the neighborhood, a local

beginning, my experiences in Arusha, Tanzania felt as if I

Tanzanian man about my age greeted me and kindly showed

was staring at one of those paintings from far away. In other

me around the village, taught me a few Swahili greetings, and

words, my impression at first was clear and beautiful. It was

even introduced me to his family. During the weekday on

without a glitch. The more time that I spent there, however,

my walk to work, I would be greeted by local Masai women,

it felt like I was moving closer and closer to the painting. By

children on their way to school, or young men asking me

the end of my trip, I was standing two feet from it.

where I was from and what I was doing in Arusha. The truth

In the hospital, it was my initial diagnostic impressions

is, having had only two months there, my limited Swahili was

that changed and became less clear. A few examples--

a major deterrent to having any real exchange, let alone a

hematemesis secondary to gastric varices with portal

conversation. Almost every day those children would run up

hypertension in a non-alcoholic with negative hepatitis B

to me and without hesitation say, “give me my money”, and

and C; three weeks of hemoptysis with a cavitary lesion on

that nice man whom I met on the side of the road was soon

chest x-ray; purple heaped up lesions in the oropharynx

asking me for money as well.

of a patient with HIV; acute meningismus and headache

My time in Arusha was filled with stories that reveal how a

in an HIV positive patient with a CD4 count of 50; acute

first impression is sometimes different than the (dirtier) truth,

severe hypoxic respiratory failure in an HIV positive patient

less clean and tidy. By no means do I think my experience

with diffuse interstitial infiltrates on chest x-ray. HIV was

was unique in that way. This is true of any real relationship--

diagnosed often, and tuberculosis suspected often. While

the longer you get to know something or someone, the more

there were certainly cases where the diagnosis seemed

you find out about the imperfections, their idiosyncrasies.

clear, the majority represented a diagnostic dilemma. For instance, many of the patients presented with findings consistent with pulmonary tuberculosis. We would begin treatment, but often these cases were met with negative sputum AFB smears (not uncommon in other settings) or a hemorrhagic pleural fluid sample suggesting the possibility of an alternative diagnosis. These cases were not as straightforward as they first seemed. Histoplasmosis, a mimicker of pulmonary TB in the immunocompromized, is difficult to test for in resource-poor settings. We neither tested for it, nor treated it here. Suspected cases of pulmonary malignancies were never confirmed given the lack of diagnostic testing. I believe that many of the patients presenting with varices were a result of infection with

I am thankful to have had my initial impressions challenged there. The truth is, what I have found is that practicing good medicine there is difficult, complicated, and never done in a vacuum. To be sure, I spent a very short amount of time abroad and therefore even to comment on what it means to practice medicine internationally is inappropriate in a way. I bet that if I were to commit to practicing long term, my perspective would change and I would have more insight into those situations that I deem as being “complicated”. However, sometimes it is the outsider who is not desensitized yet to these issues who is perhaps better able to convey this shock, as it were, that can accompany an experience that is this brief and seemingly intense.

schistosomiasis mansonii however without a liver biopsy, the

As I consider what it would be like to practice internationally

verdict is still out.

long term, I believe it would mean at least a few things.

Continued to next page

11

Chief Resident’s Corner

Hope Pogemiller, MD Global Health Chief Resident, 2014-2015

So many of us grew up

forward to building on the pioneering work of our first

convinced we were meant to

Global Health Chief, Dr. Mahsa Abassi. My goals include

“save the world,” improving life

improving the flow of communication in the global health

for individuals or populations,

pathway and continuing the mentorship program with Dr.

baby step by baby step. My

Westerhaus. I am working with Dr. Venable to strengthen

passion is to contribute to

support of residents as they participate in international

this “world-saving” in the field

opportunities with the addition of pre-departure orientation

of cross-cultural health care.

(including discussion of ethical international health

This desire was fueled by my

interactions). Dr. Boulware, Dr. Walker, and I are modifying an

International MPH training at

annual global health resident survey to evaluate the impact

Tulane and life as a Public Health Volunteer in Peace Corps Benin. My international medical exposure with La Cruz Roja Emergency Medical Service in Mexico, adult and pediatric hospitals in Haiti, and helping IOM process refugees in Uganda has inspired me further. I have had the good fortune of a strong global health education and mentorship from Dr. Settgast and Dr. Stauffer during 4 yrs of Med/Peds

of global health pathway modifications.

I will continue to introduce global health to the curriculum via morning reports and train residents to feel comfortable and work efficiently and effectively with interpreters. With each resident that our pathway inspires to confidently pursue a career involving cross-cultural healthcare, more of the world will be well on its way to a little “saving.”

Residency, and I am grateful for the opportunity to now serve as a bridge between our talented and highly motivated residents and the phenomenal mentors who are contributing

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to cross-cultural and international health care as experts in their fields. I must thank Dr. Rhodes for creating the unique Global Health Chief Resident position at UMN. I look

Alpern Continued from previous page It would mean practicing medicine within the larger context of living as a minority. It would mean being secure enough in my identity to recognize that despite the fact

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treatment of schistosomiasis. I still consider that man who asked me for money a friend. He just happens to be poor and in need of some cash. And for any resemblance of a relationship to exist between us, I learned to put up some boundaries.

that I am sinking in loan payments, I am rich. It would mean

I think the common perception of what it means to practice

recognizing my own cultural blinders—a stranger asking me

medicine internationally is akin to staring at one of those

for money is not necessarily rude and in fact doing this might

paintings, just far enough away though that the painting is

not be so strange at all (what could be more honest?) As

clear and without complication. But after spending a short

a physician it would mean becoming comfortable with the

time there, I have come to believe that without knowledge of

diagnostic uncertainties and learning how to treat based

the dots in a Georgas Seurat painting, you miss out on what

on the diagnosis that seems most likely. In my short time

makes the painting so great. Actually, if you allow yourself to

there, I have learned to adapt. In Tanzania, Praziquantel is an

get close enough, the true nature of the painting comes out

effective, cheap drug that can be given once for the empiric

and it becomes that much more beautiful.

12

Resident Highlight Brian Hilliard, M.D.

Magdalena A. Kappelman, DO I am originally from New Hampshire. I went to college at Boston University and medical school at the University

Brian Hilliard, M.D.

Ben and Magdalena Kappelman, DO

of New England in Maine, and then came to Minnesota for its Medicine-Pediatrics program. When I was in college, I

My commitment to global health has stemmed from a greater passion for addressing social and economic injustice throughout our world. I have a strong interest in the social determinants of health and view medicine as a window into the repercussions of these injustices. This view has been strengthened through various experiences throughout my training. Most recently, I have had the opportunity to participate in a course (SocMed in Gulu, Uganda) bridging the social determinants of health and current global economic, political, and historical contexts that have contributed to inequities in both health and wealth. My

took political science courses in Peru and did an internship at a medical post in the Andes mountains. I love traveling and learning about other cultures, and would like to learn how to better serve my refugee and immigrant patients. My husband is from Montana originally, and I have also been interested in working for the Indian Health Services. I have not decided what my longterm career will be yet, but I am leaning toward hospitalist medicine or critical care. I joined the global health pathway so that I could learn more about the populations I hope to work with in my upcoming career as a doctor post-globalization.

experience in the Global Health Effectiveness program at HSPH further grew my interest in developing sustainable experiences in global health that seek to address the root causes of health disparities, both locally and internationally.

I have also had the opportunity to help establish and grow a small NGO located in the Dominican Republic that works with community health workers to provide monitoring and education to Haitian migrant workers. Throughout residency, I hope to work locally to help develop a community health worker program aimed at reducing disparities in local underserved populations. I am grateful that the U of M provides an incredible amount of support and mentorship to pursue these interests. I am excited to see what the next three years, and beyond, will bring. My wife and I are

ASTMH’s Karen Goraleski Karen Goraleski, the American Society of Tropical Medicine and Hygiene’s Executive Director, spoke to the Department of Medicine’s Grand Rounds on February 27th. She delivered a powerful message about the need for a fundamental shift in how the

Karen Goraleski, ASTMH Executive Director

academic and research community communicates with key stakeholders, including Congress, the Centers for Disease Control and the National Institutes of Health.

looking forward to working together on a public health/ social medicine project during residency, whether it be

Her presentation, in its entirety is available at the following

internationally or locally.

link http://z.umn.edu/nh7 13

Is It Working

By Kristina Krohn, M.D.* Here in Arusha, Tanzania, I wonder if the ceftriaxone, an antibiotic for meningitis, that I just gave to a one-year-old child really is ceftriaxone.

The one-year-old arrived in the Intensive Care Unit actively seizing. Dora, the ICU nurse, swiftly gave doses of diazepam, a rescue antiseizure medication, and a loading dose of

Kristina Krohn, M.D.

phenobarbital, a seizure control medication. In between she was also able to give ceftriaxone to treat meningitis, an infection surrounding the brain that was likely the cause of this baby’s seizures.

India is often cited as either the leading producer of counterfeit medication, or the second, behind China. Last year, while in India I interviewed several people working to promote safe medications for low income countries.

Besides the time it took me to calculate the correct dosages, it happened faster than in an emergency room back home.

Joseph, one of the Tanzanian doctors, and I stood back with the rest of the team, watch the baby’s ragged breathing, low oxygen and prayed it would work.

The vast majority of medications produced in India are safe and legal. While India is known as the “pharmacy for the developing world”, India also produces medications you and I use and prescribe to our patients in Minnesota on a daily basis. Without lower cost good generics from India, patients

Over the past two weeks I’ve been impressed with the dedication and skills of people like Dora and Joseph.

Joseph was the first one to question the quality of the

in Africa would not have access to many medicines, and many Americans could lose access to affordable drugs as well.

ceftriaxone. He pointed out that many of our children with clinical pneumonia were not getting better, despite being on appropriate doses of ceftriaxone.

For Tanzania alone, India supplied $45.5 million dollars worth of legitimate medication in a single year (2008-2009), according to the Deccan Herald, one of the leading English

My first day here, working with Dr. Steve Swanson who

newspapers in India.

recently left HCMC to work here in Arusha, we took several children off of ceftriaxone and changed them to high-dose ampicillin. Ceftriaxone kills a broader range of bacteria than ampicillin. Ampicillin should not work better than ceftriaxone under most circumstances. But two days later, one of the children we switched improved enough to go home.

However, concerns about the quality of medications out of India sparked a visit to India by the commissioner of the United States Food and Drug Administration, Dr. Margaret A. Hamburg, where she expressed concern about the “recent lapses in quality at a handful of pharmaceutical firms”, according to the New York Times.

Was the ceftriaxone to blame? Or did the child simply have a viral pneumonia that took its own time to improve? I honestly do not know, but the seed of doubt was planted firmly in my mind.

The question is, will punishing India for failures at a few companies risk the supply of medicines to patients, like my seizing child, in low income countries. Doctors Without Borders express concern that U.S. pharmaceuticals are

Joseph said the hospital had received a shipment of inexpensive ceftriaxone from China, while Dr. Swanson thought this batch was from India.

14

Continued to next page *Director’s note: In 2012, Kristina Krohn, MD, Medicine-Pediatrics completed a very competitive one year Global Health and the Media Fellowship, co-sponsored by Stanford University and NBC News and is a regular contributor to the newsletter.

Is It Working

Continued From Previous Page

GHP Strategic Planning

pushing to change international law to prevent Indian companies from producing less expensive medications.

“We strongly object to the pressure exerted by the U.S. on developing countries, including India,” Rohit Malpani of Doctors Without Borders told the U.S. International Trade Commission in February of this year. “India’s measures are fully compliant with global trade rules and with the laws of India. These attacks undermine the global trading system.”

Ann Fandrey and Dr. Mahsa Abassi showcase the Global Health Online Community as Dr. James Nixon Looks on.

PHOTO CREDIT: Dr. Michael Rhodes

While India makes many quality medications, many Africans

15 faculty, 4 global health chiefs, 3 administrators, and 4

still do not get them. In 2005 “a random survey by the

support staff gathered in the Polar Bear Lodge at Como

National Quality Control Laboratories (NQCL) and the

Zoo on March 1st for the first annual Global Health Pathway

Pharmacy and Poisons Board found that almost 30% of the

faculty Strategic Planning Retreat. Even the polar bear

drugs in Kenya were counterfeit” according to the WHO.

outside the window could not distract participants from a

The Indian government believes its drugs are not to blame,

lively and very engaging discussion.

but others using their good name. Gurjit Singh, Joint

Faculty participants included individuals from the University

Secretary in the East and Southern Africa Division of the

of Minnesota, Abbot,

Ministry of External Affairs in India is quoted as saying, “It is

Hennepin and

now clear that the fake drugs being sold in Africa with the

HealthPartners. The

‘Made in India’ tag are not produced in India, but elsewhere”

group heard from

according to the Deccan Herald.

faculty leadership on

This brings me back to the one-year-old child seizing in front of me. His oxygen level slowly increased, and his breathing calmed as the seizure medications worked. I sat down to write his admission as his eyes slowly came back into focus.

Joseph and Dora moved away from his bedside, and his mother – who had not said a word apart from when asked – sat down beside him. A brief smile of relief came across her face when he cried out and reached for her hand. The

the history and growth of the pathway, the importance of the

A curious Polar Bear outside of Global Health Pathway Strategic Planning Session

work being done and a review of the year’s highlights and successes in education, research and development. Mahsa Abassi also shared her accomplishments over the past year and her vision for future Global Health Chief Residents.

seizure had stopped. I know the seizure is done, but I don’t

The group participated in a SWOT Analysis discussing the

know if he is out of the woods. He likely has meningitis.

Global Health Pathway strengths, weaknesses, opportunities

Ceftriaxone is the main treatment for bacterial meningitis

and threats and then brainstormed a list goals in the areas

for a kid this age, and if it is not working I do not know what

of general operations, clinical care, medical education and

to do next. I will be relying on Joseph and Dora. And we may

research.

not have an opportunity to try something different.

Over the next several months, faculty will discuss these goals

When I come home I may try to bring a sample of the

further, and develope strategies to achieve those goals which

ceftriaxone with me, so that I can test its quality. But until

will help inform and define the pathway’s Mission, Vision

then, I just hope it works.

and Core Values.

15

Global Health Course The 9th Annual Live Global Health

Participants were immersed in medical

Pathway came to an end on May 30th

simulations, engaged in didactic training,

concluding a four week course focusing

classroom lectures, and laboratory

on Immigrant and Refugee Health,

activities and prepared for the

Tropical and Travel Medicine and

American Society of Tropical Medicine

Operationalizing Global Health. This

and Hygiene (ASTMH) Exam.

year’s course brought 47 global healthfocused health care professionals from the University of Minnesota other local, national and international institutions together with over 89 speakers and experts in their respective fields.

Next year’s course is tentatively scheduled for May 4-26, 2015. Please visit our website for more information as the date progresses. www. globalhealth.umn.edu/education/globalhealth-course

2 01 4 G l o b a l Hea l t h G ra d u a t e s Jon Alpern, MD Chief Resident Regions Hospital, St. Paul, MN Noah Goldfarb, MD Internal Medicine - Dermatology, Academic Practice Adam Foss, MD Chief Resident, Pediatrics University of Minnesota Lauren Haveman Bergmann, MD Chief Resident, Med-Peds University of Minnesota Carolyn Newman, MD Primary Care Rochester, MN VA Clinic Sheila Nguyen, MD Med-Peds Hospitalist University of Minnesota

Dr. David Boulware presents to course participants

Dr. Brett Hendle-Paterson presents to course participants

Hope Pogemiller, MD Global Health Chief Resident University of Minnesota

Additional Global Health Pathway course participants graduating from their residency program IM: Ian Chang, Ethan Craig, Ryan Greiner, Chul Kim, Michael Newman, Kevin Rank Dr. Sheila Nguyen, Med-Peds Hospitalist

patient-simulation exercise

MedDerm: Catherine Manabat MedPeds: Eric Bomberg, Aaron Grauman Peds: Danielle Brueck, Sansanee Craig, Emily Hall, Katie Satrom, Michael Taylor, Jose Jimenez Vega Global Family Medicine: Jeremiah Eisenschenk, Muna Jama

course participants 16

Dr. Tina Slusher and course participants

HCMC: Danielle Haselby, Melanie Lo, Lubna Shabnam

CONGRATULATIONS GRADUATES! 1st Annual Global Health Graduation and Research Symposium Hosted by the Departments of Medicine and Pediatrics

Drs. Jose Debes, Brett Hendel-Paterson & Ann Settgast

Drs. David Boulware, Chandy John, Mike Pitt & Pat Walker

Drs. Mahsa Abassi & Mike Rhodes

Dr. Adam Foss with his poster presentation

Drs. Danielle Dhaliwal Cindy Howard, Tina Slusher, and Ryan Fabrizius discussing Danielle’s poster

Dr. Joe Messana with his poster presentation

graduation attendees along with Dr. Pat Walker

AJ Colianni and Drs. Sonja Colianni & Mike Pitt

Drs. Jon Alpern, Mike Rhodes, Katie Anderson, and Anteneh Zewde

Drs. Mike Taylor, Heather Brook, Cindy Howard, Tina Slusher and Kristina Krohn

Dr. Nate Herr with his poster presentation

Drs. Ryan Fabrizius, Mahsa Abassi, and James McCabe

17

Are You Ready for a Humanitarian Emergency?

Enroll in the Humanitarian Crisis Simulation Course Friday, September 5th, 8:00 a.m. — Sunday, September 7th, 1:00 p.m.

Cannon Falls, MN The Humanitarian Crisis Simulation is designed to immerse participants in an environment typical of humanitarian crises.

The simulation will equip participants with knowledge, experience and skills that will assist them in working in any humanitarian crisis.

This course is offered to practicing physicians, other professionals and medical trainees.

One graduate credit is offered in course PA 5890 – Crisis Simulation.

Fee: Includes two nights camping and all meals

• Physicians and other professionals: $295 • Medical trainees or Global Health course participants: $40 • Students enrolled in PA5890: Fee waived For More Information E-mail: umnsim@umn.edu Web: http://z.umn.edu/mxk

The University’s mission, carried out on multiple campuses and throughout the state, is threefold: research and discovery, teaching and learning, and outreach and public service. The University of Minnesota is an equal opportunity educator and employer. This publication/material is available in alternative formats upon request. Direct requests to Danielle Brownlee, dtbrown@umn.edu or 612-625-6922.

Printed on recycled and recyclable paper with at least 10 percent postconsumer waste material. © 2010 Regents of the University of Minnesota. All rights reserved.

Rev Up Your Review

A fully updated ASTMH CTropMed ® Online Exam Review Moodle site is now live and available to help you prepare for the CTropMed® exam coming up November 11, 2014. The quiz-based review features 5 practice exams, 21 topic-based quizzes with custom feedback, and downloadable study files. Previous users of the review have given it rave reviews for its usefulness in preparing for the CTropMed exam. Global Health Pathway trainees have free access to the site, and it is also available free to anyone who has purchased 2 or more modules of the Minnesota Online Global Health Course. All others, please see pricing here (http://www.globalhealth.umn.edu/education/Pricing/index.htm).

CDC’s Dr. Martin Cetron at season’s last Tropical and Travel Medicine Seminar Dr. Martin Cetron, Director,

#UofMTTMS

Global Migration and Quarantine for the Center’s for Disease control spoke at the season’s last Tropical and Travel Medicine Seminar on May 22nd.

More information on upcoming seminars will be available on our

Dr. Kate Venable presents at the Sept. 18, 2013 Tropical and Travel Medicine Seminar.

website when they resume on September 24, 2014.

Department of Medicine

Global Health Spring 2014 Published quarterly by Global Health, Department of Medicine, University of Minnesota To request disability accommodations, please contact Danielle Brownlee at dtbrown@umn.edu

To find out how you can make a difference, please contact:

The University of Minnesota is an equal opportunity educator and employer.

Russell Betts, Development Officer 612-626-4569 or rbetts@umn.edu

© 2014 University of Minnesota All rights reserved.

www.globalhealth.umn.edu

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/