Internship report Rachel Hutchinson 2014 May

Internship Report

Rachel Hutchinson Supervisor: Dr Luis Gabriel Cuervo Research Promotion and Development Department of Knowledge Management, Bioethics and Research Pan American Health Organization Feb 17 2014 – May 30 2014

Internship Report for Rachel Hutchinson, May 2014

Contents

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Summary Introduction Terms of reference Internship activities relating to TOR Internship activities within PAHO in addition to TOR Activities outside of PAHO Assessment and conclusions

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Internship Report for Rachel Hutchinson, May 2014

1. Summary

Between February 17 2014 and May 30 2014 I worked as an intern in the Department for Knowledge Management, Bioethics and Research at the Pan American Health Organization, Regional Office for the World Health Organization in Washington DC. I was working under Dr Luis Gabriel Cuervo with the Research Promotion and Development team.

The main tasks as outlined in my Terms of Reference (TOR) were to complete a characterization of clinical trials done on maternal and child health in the Americas and to contribute to ongoing surveys assessing the extent of implementation of the PAHO Policy on Research for Health (CD49/10) both in the Pan American Sanitary Bureau and in the PAHO member states.

During this internship I managed to complete almost all of the tasks in my TOR to the best of my ability and will endeavor to finish those that remain incomplete on my return to the United Kingdom. I had the opportunity to contribute to many projects in addition to those outlined in my TOR. I feel that I really made the most of my time in Washington DC and took advantage of all the opportunities on offer to me in PAHO and further afield.

I have developed skills and knowledge that will continue to serve me well throughout my professional career. I have met many inspirational people and forged some life-long friendships. It has been a true privilege to intern in such a prestigious organization.

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Internship Report for Rachel Hutchinson, May 2014

2. Introduction

As a resident in Obstetrics and Gynecology, I do not come from a Public Health background. I have previously studied an undergraduate degree in International Health but have no work experience in this field. I noticed that since my graduation I had come to feel increasing frustrated with the role that clinicians play in making an impact on the wider determinants of health. As a clinician it is easy to become blinkered and I occasionally felt that all we did was ‘plug the dam’ rather than make any real difference in terms of policy and health systems. Ultimately this limits the impact we have on prevention of adverse maternal and neonatal outcomes. It became clear to me that in reproductive health in particular it is essential to maintain a balanced and holistic outlook. In Obstetrics and Gynecology, the concept of health is so closely interlinked with law, politics, religion and socio-economic status. More so than any other specialty I have worked in.

It was for these reasons that I decided to take a break from my residency training to gain a broader perspective on health and some practical public health experience, with the view that I may consider working in the Public Health arena in the future.

The decision to come the Pan American Health Organization (PAHO) was easy for me. It was the chance to work in the oldest and one of the most prestigious Public Health institutions in the world. It would also allow me the unique opportunity to work within the United Nations and the Inter-American system.

Having previously worked and lived in South America, I was also keen to have the opportunity to immerse myself again in Latin American culture and improve my language skills.

I chose to conduct my internship in the Department of Knowledge Management, Bioethics and Research (KBR) and more specifically with Dr. Luis Gabriel Cuervo in the Research Promotion and Development Team. In the UK I had been involved with multiple small research projects, literature review and multiple audits and monitoring and evaluation exercises, hence, I felt that in this department I would be able to both learn a lot of useful skills but also contribute something worthwhile. In particular, I was keen to learn more about research capacity in low and middle income countries, research priority-setting, how research is incorporated to guidelines and policy, monitoring and evaluation, and the role that PAHO plays in all of this.

Additionally, I was keen to learn what my role as a clinician should be with regard to research promotion and development at a ‘grassroots’ level and especially when working overseas in low and middle income countries.

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Internship Report for Rachel Hutchinson, May 2014

3. Terms of reference

Listed below are the terms of reference that were agreed for my internship. I was lucky enough to be allowed to concentrate on maternal and reproductive health.

1. Characterization of clinical trials done on maternal and child health research, analysis of maternal and child health issues in the national research agendas 2. Contribute towards the surveys on the implementation of PAHO's Policy on Research for Health at PASB 3. Support the development of the Strategy on Research for Health 4. Produce an analysis of research registered in PAHO 5. Write a case study relevant to a topic for which you feel passionately about 6. Contribute to internship activities such as; organizing a research interest group, participating in visits 7. Prepare a report for the duration of the internship following with the format and structure offered by your supervisor

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Internship Report for Rachel Hutchinson, May 2014

4. Internship activities relating to TOR

Characterization of clinical trials done on maternal and child health This characterization was to be my main project during my internship at PAHO. It quickly became apparent that this project would need to be split into two separate characterizations. One characterization would be of clinical trials done on maternal health, and a second for child health, or more specifically neonatal health.

I began with the characterization on maternal health clinical trials and under the guidance of my supervisor, Dr Luis Gabriel Cuervo, we came up with a list of questions that we would like to address in the characterization.

The aim was to characterize clinical trials on maternal health that are registered in ICTRP data providers in order to gain a greater understanding of a variety of trial variables, identify areas of under and over investigation and describe which collaborations most commonly exist in terms of countries, sponsors, funding, conditions and interventions. The final report was to include specific, action oriented recommendations to improve the equity and value of research for health in the Americas.

More specifically we were hoping to address and describe to following questions, topics and relationships, amongst others;  

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Conditions and interventions: Which conditions and interventions are most frequently addressed in the registered trials? How do these variables compare by country and sponsor?

Funding and sponsors: What private, public and mixed entities fund and sponsor research in this field and how does this compare to conditions and countries involved? Does the nature of the source of funding vary by country? What are the most frequently seen collaborations? Which funds or sponsor the most trials and have the largest numbers of participants?

Countries of recruitment: Which countries perform the most maternal health research? How frequently are registered multicenter clinical trials of an international nature? What countries participate in them?

Study type: What study types and designs are most registered and how does this compare with hierarchy of evidence? Does the type vary by country and sponsor?

Target sample size: How does the sample size relate to the participating countries?

Inclusion/exclusion criteria: Do these trials include marginalized populations and minorities such as indigenous groups or teens?

I produced a draft protocol and with the help of Dr Ludovic Reveiz, Advisor on Health Research Management, the search strategy was finalized and a data collection tool in MS Excel was made.

Unfortunately I have not yet been able to complete the maternal health characterization. The data collection has been done but for various reasons, mostly relating to time constraints, the analysis is pending. With regard to the characterization on neonatal clinical trials, the draft protocol is written but Page 6 of 15

Internship Report for Rachel Hutchinson, May 2014

the data collection has not yet been started. These are two projects I plan to complete in my own time upon my return to the United Kingdom.

Also relating to these characterizations I reviewed the protocol of my fellow intern Dr Jose Miguel Uribe, who was conducting a similar characterization of clinical trials done on mental health and I assisted another intern Bridget Lee in planning her search strategy in ICTRP.

Contribute towards the surveys on the implementation of PAHO's Policy on Research for Health at PASB The PAHO Policy on Research for Health (CD49/10) was approved by all member states and PASB in 2009. Implementation of the policy had not previously been assessed but this was deemed a necessary step, supported by PAHO’s director, to advance the policy and work towards its complete implementation by senior management.

Dr Luis Gabriel Cuervo and a previous intern, Stefanie Soelling, had set out to establish baseline data on the state of implementation of the PAHO Policy on Research for Health and identify what is being done well and areas for improvement with recommendations. They designed, tested and implemented a survey which consisted of twenty multiple choice questions which were sent to forty-five PAHO managers. There were twenty respondents.

I was asked to contribute to the final report by reviewing the findings of the survey and drafting the abstract, discussion, limitations and recommendations sections. The report is now complete and has been submitted to PAHO managers and the Executive.

The findings were encouraging and show that many aspects of the PAHO Policy on Research for Health are being implemented by senior staff. Two main areas of concern were identified. They are; low adherence to research registration at PASB, and poor compliance with standards and processes for guideline formulation and the review of research protocols. Various recommendations to improve implementation in these areas were proposed including; the delivery of periodic reports about PAHO’s investment of resources, production and use of research, and promotion of research registration and compliance with the standards for guidelines and recommendations.

Support the development of the Strategy on Research for Health Further to the PAHO Policy on Research for Health discussed above I was asked to continue the work that had been started by a previous intern, Jimmy Toan Le. He had made great advancements with regard to two key documents and during his internship he had worked on the following under the guidance of Dr Luis Gabriel Cuervo, Mrs Eleana Villanueva and Dr Rosina Salerno; 

Editing and expanding a draft Strategy and Plan of Action for the Research for Health Policy

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Developing a methodology and assessment tool to assess implementation of the PAHO Policy on Research for Health in member states.

The Tool takes the form of 36 Likert scale questions. Six questions were devised from each of the six objectives in the Policy. Respondents from each PAHO member state would be asked to answer the questions. The aim was for the Department of KBR to learn about the status of the implementation of the Policy within individual countries. Responses will guide the planning of capacity building, enhance research management tools, and contribute to the accuracy of data management.

Jimmy Toan Le had advanced the tool to the point that it had gone to the ACHR for further consultation.

I worked on furthering this process by reviewing the ACHR responses and updating the tool in SurveyMonkey™ with the committee members’ suggestions for improvement. I reviewed and updated the Methodology along with my fellow intern Dr Jose Miguel Uribe, who also translated the document to Spanish. I prepared a GANNT chart to outline the process and timescale of implementation of this assessment tool, drafted emails to potential respondents and the Assistant Director, and started to compile a list of potential respondents. This list will comprise of a representative from the Ministry of Health and National Council of Science and Technology for each PAHO member state.

The next step in this process will be to liaise with the Organization of American states to complete the list of potential respondents and to consult with the Assistant Director to gain approval to begin data collection from PAHO member states. A summer intern from McMaster University will be working on this in the coming months.

Produce an analysis of research registered in PAHO I was advised by Dr Cuervo that unfortunately we do not have access to the data that is required to complete this task at present. This will most likely be a task for a future intern.

Write a case study relevant to a topic for which you feel passionately about I relished the opportunity to write a case study on a topic of my choosing. As a trainee in Obstetrics and Gynecology it is clear where my passion lies. The aim of the case study is to discuss examples of how research for health has enabled equitable socio-economic growth across all sectors.

The first case study I wrote was about the landmark ‘Magpie Trial’ [1] and how international collaborations with researchers in the Americas transformed the treatment of pre-eclampsia, a condition that disproportionately affects those living in low and middle income countries and the leading cause of maternal mortality in Latin America and the Caribbean [2] [3]. Two very prominent professionals from the research field, Sir Iain Chalmers and Professor Lelia Duley, were asked to peer review my work, this was a great privilege for me.

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Internship Report for Rachel Hutchinson, May 2014

With a lot of help from fellow interns Natalia Godoy and Isabel Lansberry the case study was translated to Spanish and now appears on the PAHO website in both languages.

My second case study was about the development of the oral contraceptive pill and how the benefits of family planning extend far beyond the sphere of health. Not only does access to contraception save the lives of both mothers and babies, it benefits society as a whole in terms of the economy, education, equality and the environment. The case study was once again peer reviewed by the eminent Dr Marijke Velzeboer-Salcedo and Dr Carlos Ă lvarez-Dardet. The Spanish translation for this piece is pending but the English version of the case study can also be viewed on the PAHO website.

Contribute to internship activities such as; organizing a research interest group, participating in visits and other activities as needed I had the opportunity to organize one of the Research Interest Groups held by the Research Promotion and Development team and helped out with two others. We were very excited to welcome Claire Allen, Knowledge Manager at Evidence Aid to PAHO in early May. I worked with Audrey Johnson, an intern in the Department for Emergency Preparedness and Disaster Relief to organize the lunch time meeting.

Evidence Aid is an international initiative based in the United Kingdom and Republic of Ireland that provides timely access to reliable and up-to-date knowledge from systematic reviews of relevance to natural disasters and other humanitarian emergencies. The meeting was well attended by interested individuals from almost all PAHO technical departments including KBR, PED, FGL, NMH, HSS and SDE. We also welcomed several external guests from the World Bank, International Monetary Fund and Georgetown University faculty.

I helped to publicize the Research Interest Groups by contributing to social media pages for interns with photographs of the Research Interest Groups and by writing PAHO bulletins to be sent to staff members in PAHO HQ. In terms of other activities I was responsible for organizing a trip to the World Bank for all PAHO interns.

Over twenty attended on the day. We had the opportunity to tour the building and learn more about the history and role of the World Bank Group.

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Internship Report for Rachel Hutchinson, May 2014

5. Internship activities within PAHO in addition to TOR

Along with the projects outlined in my TOR I had the chance to contribute to several other projects and activities.

I was excited to have the opportunity to peer review an article for the British Medical Journal with Dr Cuervo and Natalia Godoy. This was a very interesting task, allowing me to develop my critical thinking skills and learn more about the process of peer review and how research is selected for publication.

I attended a funding meeting for a project jointly proposed by COHRED and PAHO to USAID. I took minutes and contributed to the final report that was compiled by Natalia Godoy. Following this meeting I helped to moderate a virtual Blackboard conference between COHRED/PAHO and other potential funders. I had previously been trained by Eleana Villanueva in how to moderate Blackboard conferences and webinars.

I attended several other important meeting at PAHO Headquarters including but not limited to;    

The Biannual Assessment of Work: Strategic Objective Final Assessment for the Strategic Plan 20082013 Sir George Alleyne’s presentation on his work with the Lancet Commission Report “Global health 2035: a world converging within a generation” International Women’s Day event which was introduced by our Director, Dr Carissa Etienne and followed by a film “To Educate a Girl” The Directors dialogue with staff

Along with other PAHO interns I was involved with organizing the PAHO Commemoration of World Tuberculosis Day 2014. My duties involved meeting and assisting delegates from across the region and publicizing the event on social media.

World Health Day 2014 was to raise awareness about vector-borne diseases. I volunteered to be part of a team to travel to Dulles Airport to educate members of the public on how to protect themselves and their family against vector-borne diseases.

Also in PAHO I attended several toast masters meetings and took Rosetta Stone Beginners French classes. In addition to the French classes, my ability to communicate in Spanish has significantly improved over the course of the last 3.5 months.

In my final week I was able to make some small contributions to the departmental Research Newsletter.

This will be disseminated to a wide audience, both internally at PAHO and externally amongst collaborators and other interested parties.

I attended and participated in a departmental retreat along with other KBR interns and KBR staff. The aim of the retreat was to develop a vision for the department and identify future lines of work and Page 10 of 15

Internship Report for Rachel Hutchinson, May 2014

priorities. The retreat was held at the Organization of American States and was an opportunity to get to know other members of the department including the Director of the department, Marcelo D’Agostino and the Assistant Director of PAHO Dr Francisco Becerra-Posada.

Further to this, working at PAHO has also given me the chance to meet and speak to various other important leaders in public health including PAHO Director Dr Carissa Etienne and WHO DirectorGeneral Margaret Chan.

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Internship Report for Rachel Hutchinson, May 2014

6. Activities outside of PAHO

Outside of PAHO I have taken the initiative to attend numerous conferences, talks and activities during my time here in Washington DC. These events have related to health and other personal interests of mine and some are listed below;    

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Organization of American States Policy Roundtable on Women and Drugs in the Americas Organization of American States Lecture Series – President of the International Court of Justice in the Hague – Peter Tomka Organization of American States Lecture Series – President of the World Bank – Jim Yong Kim Joint World Health Organization and World Bank conference on Universal Health Coverage 2030. I had the opportunity to see various eminent speakers including Ban Ki Moon, Margaret Chan, Jim Yong Kim, Lawrence Summers, Michael Bloomberg and Tim Evans.

Film and panel discussion at Georgetown Law on access to antiretroviral drugs and pharmaceutical patenting laws. The panel discussion included Congressman Jim McDermott and representatives from MSF and other NGOs. Also at Georgetown Law I attended a lecture on conscientious objection to performing abortions.

An event raising awareness of Female Genital Mutilation at International Student House which I was involved in organizing Multiple film screenings in the annual Washington DC Environmental Film Festival at locations including the National Academy of Sciences, Smithsonian Museums, Goethe Institute and Georgetown University. Of particular interest were films documenting the relationship between health and climate change and how the world’s poorest populations are being disproportionately affected, including in the Americas The Consortium of Universities on Global Health Annual Conference which included speakers such as Richard Horton, Editor-in-Chief at the Lancet and Peter Piot, Director of the London School of Hygiene and Tropical Medicine Red Cross Refugee Simulation Day

Throughout my time in Washington DC I have had the opportunity to network and socialize with interns outside of PAHO including interns working in organizations such as the Inter-American Development Bank, World Bank, Organization of the American States and National Institute of Health and those working further afield in the White House, Capitol Hill and various embassies. Most work outside of the health sphere in law, politics, economics and the environment. Through these new friends I have come to broaden my horizons and gain a greater appreciation of the wider determinants of health.

With PAHO interns I have visited New York, Lake Anna State Park in Virginia, photographed cherry blossoms, cycled from Washington DC to Mount Vernon and even ran 5K for charity! I feel that I have formed some life-long friendships in Washington for which I am very grateful.

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Internship Report for Rachel Hutchinson, May 2014

I have been very privileged during my time here to be asked to volunteer at the White House Annual Easter Egg Roll, attended by President Obama and the First Lady. I was also invited to see the President speak at Arlington National Cemetery on Memorial Day. I visited the Pentagon and was fortunate enough to meet Secretary of Defense Chuck Hagel. All these special experiences with stay with me for a long time and I feel incredibly lucky.

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Internship Report for Rachel Hutchinson, May 2014

7. Assessment and conclusions

This internship was a wonderful experience that far exceeded my expectations. It has not only given me practical experience in the public health sphere, it has reinvigorated my passion for my career in Obstetrics and Gynecology and my aspirations for the future. The scope of what I have achieved and been part of extends far beyond my initial terms of reference as evidenced by the activities detailed above. I have had the opportunity to meet some truly inspirational people.

I have realized that upon my return to the UK, I would like to take a more active role in conducting research and gain more experience in evidence-based policy formation and implementation. As a clinician I have a moral and professional responsibility to stay abreast of new developments, and implement this evidence to my own practice and that of my colleagues.

The projects I have been working on in PAHO have given me the opportunity to take initiative and work both independently and in a team. I have improved my skills searching for and using literature and research. I have also learnt a great deal about knowledge translation and I have become aware of tools and initiatives such as ICTRP, Health Research Web, EQUATOR Network and EVIPNet that I am sure I will continue to use throughout my professional career.

I come from a country which already places great importance on the value of evidence-based practice, monitoring and evaluation and good ethical conduct. I had rather naively assumed that these same standards exist everywhere and realize that in the future when working overseas as a clinician I have a responsibility to help to build research capacity in low and middle income countries. I can do this through forging new research collaborations and teaching healthcare professionals about research methods, ethics, standards for guidelines and monitoring and evaluation.

It has been an honor to work within the UN system in such a prestigious organization as PAHO. I was very pleasantly surprised with the level of trust and responsibility that I was given by my seniors.

Everyone I have worked with has been very approachable and keen to give up time to help in anyway. It is particularly nice to feel that our opinions are valued and on several occasions seniors such as our departmental Director Marcelo D’Agostino, have gone out of their way to actively seek intern opinions and input. This has made the experience so much more rewarding.

One of the most fulfilling aspects of the internship is that I have made solid connections with other interns and professionals that I will continue to work with throughout my career, both in the UK and overseas. The opportunities I have been granted as a result of my PAHO internship are second to none.

Living and working in Washington DC has been a truly amazing experience and one I will always cherish.

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References

[1] The Magpie Trial Collaborative Group, "Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Mgpie Trial: a randomised, placebo controlled trial," Lancet, no. 359, pp.

1877-1890, 2002.

[2] World Health Organisation, "World Health Report 2005: Make every mother and child count," World Health Organisation, Geneva, 2005.

[3] Khan K, Wojdyla D, Say L, G端lmezoglu AM, Van Look P, "WHO analysis of causes of maternal death: a systematic review," Lancet, no. 367, pp. 1066-74, 2006.

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