Come one, come all!

GHIG will be holding its first general body meeting of the school year this Wednesday, September 29, from 1-2pm in AMEB room 220. We will be announcing several exciting new initiatives as well as discussing opportunities for new members to get involved in our activities.

At these meetings we typically open by discussing a short article of global health relevance. Wednesday’s article from NEJM is of particular interest to students in the health professions: “An International Service Corps for Health – An Unconventional Prescription for Diplomacy.” We will have a few paper copies at the meeting if you don’t have time to read it beforehand.

Hope to see you there!

Dementia…it’s not all in your mind

Not unlike my friends who traveled to foreign locales and researched various subjects impacting global health, I spent the summer in the exotic, scenic waterfront city of…Baltimore…working on memory disorders research. My project focused on developing a numerical rating scale for assessing and quantifying dementia severity. The current standard clinical rating scales rely heavily on memory, where Alzheimer’s commonly reveals itself first; however, there are a whole host of functional domains – orientation, behavior, language, judgment – that commonly manifest descriptive symptoms of cognitive decline. By measuring the disease progression in some objective way, we can record the natural history of disease and develop further therapeutic or management strategies.

How is this relevant to global health, you may ask.

Well, as Atlas and Axis’s self appointed geriatrics correspondent and honorary senior citizen, I wanted to draw your attention to a recent study on the global cost of dementia, “The World Alzheimer Report 2010” issued by Alzheimer’s Disease International. The study features staggering statistics for the global economic and epidemiologic impact of dementia over the next 20 years.

Alzheimer’s is the most common and most well-known form of dementia, though there are numerous types of dementia that affect memory, executive function and comportment. Fatal and progressive, dementias can cause cognitive deficits that come to interfere with daily life and functioning, such as the ability to make simple decisions, to recognize family members or to dress oneself. In the moderate to severe stages of disease, patients become completely dependent on caregivers, leading to stress and depression for patients and caregivers alike.

In 2009, there were an estimated 35.6 million people living with dementia global, and this number is expected to double by 2030. (Americans account for 5.3 million of these patients). Alzheimer’s and other dementias are not simply diseases of high income countries; these diseases are prominent in such low and middle income countries as Cuba, Dominican Republic, Mexico, India, China, and Peru.

Not surprisingly, the societal burden of disease is matched by an economic burden.  This year, the global cost of dementia is estimated to exceed $604 billion, surpassing the annual revenue of Walmart ($414 billion), for example. On an individual level, the average cost of caring for an Alzheimer’s patient is anywhere from $18,000 to 77,500 per year. Though many scientist, healthcare practitioners and physicians have devoted themselves to the study of the disease, there is currently no cure for Alzheimer’s disease.

Sadly, the impact of dementia is often unnoticed and its onset attributed to “old age” or “senility.” With worldwide life expectancies increasing and the 65 and over population rising sharply in the next few years, the elderly are becoming an underserved and overlooked population. I know that my miniscule research project will not remove the social and economic difficulties of dementia, nor will it move us closer to a cure, but I hope that, in some small way, we can gain a better understanding of the global picture of dementia.

Leprosy: The Orphan Disease

“Do we still have leprosy?”

A businessman in Bombay asked me this when I told him about my research. I had a hard time stifling laughter (totally inappropriate, but I was pretty tired), because for the last six weeks, six days out of the week, all I had seen were cases of leprosy: in government hospitals, skin clinics, VD (venereal disease) clinics, NGOs, and even swanky private establishments.

WHO blister packs of multidrug therapy (MDT) for leprosy - Rifampicin, Clofazimine, Dapsone

Leprosy is almost everywhere and simultaneously nowhere in India. The country carries 1/3 of the global burden of disease. In December 2005, India achieved the WHO’s standard of leprosy elimination (less than 1.0 cases per 10,000), with the goal of eradication in 20-25 years. As of 2009, however, the WHO reports India to have a 1-2.0/10,000 prevalence rate of leprosy. And prevalence is often higher in some areas. So, while the countrywide picture is quite good, urban and rural pockets still carry a large burden of disease.

Bombay supposedly has a low prevalence (0.53/10,000), but as R. Ganapati, former head of the Bombay Leprosy Project, states, in areas of poverty — especially the city’s sprawling slums — the prevalence can be much higher (3-4/10,000).  I did some of my research at the BLP, which is close to Bombay’s large Sion government hospital, in the Sion-Chunabhatti district of the city. The expansive Dharavi slum (made famous and notorious in the movie ‘Slumdog Millionaire’) feeds into this area, and many leprosy patients come fom here to BLP and other NGOs for care.

Global Health events this week!

Hello global health folks,

Just wanted to keep you abreast of some events taking place this week. If you know of anything else that would be of interest, please share!

Tuesday September 14, 3:30pm (yes, TOMORROW!!!)

What: Accordia 2010 Celebration of Partnership–Student volunteers needed to help with set-up!
Who: U.S. Ambassador-At-Large and U.S. Global AIDS Coordinator John Goosby, 3 senators, health experts, etc…
Where: US Capitol Visitor Center, Washington, DC
Also: Please get in touch with Megan Buresh (MS2) if you can make it

Wednesday September 15

10am
What: Live webcast, “Patient Safety: Progress and Dilemmas”
Who: Sir Liam Donaldson, Chairperson of the WHO Patient Safety Programme
Where: Webcast link
Also: More info on the WHO’s patient safety initiatives here

Noon
What: Seminar, “Indo-US collaboration on science and technology” (Hopefully some insight into implications for access to medicines and medical technologies?)
Who: Meera Shankar, Indian Ambassador to the US, and Michael Klag, Dean of the Bloomberg School of Public Health
Where: Bloomberg School of Public Health, Sheldon Hall, W1214

Thursday September 16

Noon
What: Seminar, “Tuberculosis Drug Discovery: New Inhibitors for an Old Disease”
Who: Ronon O’Toole, Victoria University of Wellington.
Where: Bloomberg School of Public Health, CRBII, Conference Room 111

Also at noon
What: Research seminar, “Structural Biology and Tropical Diseases”
Who: Wim G.J. Hol, University of Washington
Where: Bloomberg School of Public Health Wolfe St. building, W1020 Becton Dickinson Hall

2:30pm to 4:30pm
What: Another webcast! “Fault lines in Global Health; Resolved: that the Global Fund to Fight AIDS, Tuberculosis, and Malaria should be transformed to become the Global Fund Health”
Who: Mark Dybul, Georgetown University and former US Global AIDS Coordinator vs. Julian Schweitzer, Results for Development Institute
Where: Here’s the link!

Transnational Partner Notification

Seems like a logistical nightmare right?

But I think we need it. 

The minimal legal and ethical obligation of STD/HIV notification for doctors treating patients in the U.S. is clear – you report it to the local health department and let their disease intervention specialists (DIS) track down potentially at-risk sex or needle sharing partners and let them know they’re at risk for acquiring an HIV or another STD.  But what do you do if your patient is an immigrant from another country, has been diagnosed with HIV in the U.S. and you’re pretty sure he hasn’t told his wife, who is  still living at home in their country of origin?

Working with HIV+ Latino immigrants in Baltimore, this was a common scenario.

What is our duty as physicians and public health providers to these partners (usually wives) back at home?  How can we ensure they are tested – especially considering that typically, they have only ever had sex with their husband and therefore may not perceive themselves at enough risk to be tested.  And they may have more kids.

I’m not sure how we would notify people – it would require system of different countries’ health departments sharing information, and protecting confidentiality of HIV+ patients in transfer could be tricky -but it seems like there’s a need for some kind of public health Interpol service to help ensure partner notification, regardless of which country that partner might be living in.

Reflections on Latino HIV Outreach in Baltimore

So while the past few years I’ve spent a lot of time globe-trotting, this summer I decided to stay in Baltimore, not-so-secretly jealous of everyone else who was traveling and wondering if I should have traveled, despite the short summer.

But on my first day of work with the Baltimore City Health Department’s Latino HIV Outreach Team made me feel like I was back at my last job in Cambodia – everyone was speaking Spanish (I’ve only started to learn over the last year through once-a-week medical spanish classes), my boss had to run off to a funeral leaving us abandoned at Esperanza Center and the person we were supposed to meet with to show us around was MIA.  It took a few hours, but we eventually figured out that she had called in sick.

Despite that somewhat ominous start to the summer, it ended up being a good one.  The Latino Outreach team is 2 years old and they do HIV testing and follow-up care using a mobile unit and at fixed site like Esperanza Center.  The Latino population in Baltimore is growing, and most are recent immigrants (last 5-10 years), who speak little English, may be undocumented and have little access to the healthcare system.  There is also a lot of fear surrounding HIV.

While the main project we were supposed to do (write a survey fto assess HIV risk behavior in MSM) got delayed, we got to work on some shorter venue assessments for future surveys, lay the framework for a Spanish-speaking HIV+ peer support group (there are currently none in Baltimore), help organize a Latino Health Fair (280 served!) and network with other community organizations to see what insight they would have for future surveys and community outreach. 

Best of all, I got to hang out with the community outreach workers – who without fail always seem to be really cool people.  Some of their outreach includes mobile testing on Friday and Saturday nights at local bars (usually the ‘sketchiest’ ones – with commercial sex workers or other high-risk behavior is likely to happen).  As Unfortunately, I was only able to shadow with the mobile unit once (it was a long, cursed summer for that van, it seems it was either broken down, the weather was bad or there was no driver).  But Despite my limited Spanish, they pushed me to help with HIV testing – so I got to figure out how to say questions like, “Have you ever exchanged sex for drugs or money?” and then try to figure out if they were laughing at my Spanish or the awkwardness of the question.  Probably both.

Another refreshing thing about my summer was how open to collaboration my P.I. and rest of the staff was.  I’m used to researchers being quite territorial but we were able to partner with a support group at University of MD (our so-called Baltimore ‘rival’) for the one we were starting and even at last-minute notice, the Latino Outreach Team was willing to help with a faith-based HIV testing initiative called City Uprising to help facilitate testing at Esperanza Center – even though the paperwork and system tused were mostly those of another organization.  And that day, over 100 people were tested at that site!  I look forward to seeing how these collaborations continue to progress.

I don’t come away from the summer with any pending publications and I’m not sure what I’ll put on my scholarly concentrations poster (hopefully we’ll have IRB approval and some results on the shorter survey by next spring??) – but I did get to work at the interface of Hopkins, the health department and other faith and community-based organizations – and I think that’s where I’d like to continue to be in the future – some time with PubMed, some time in the clinic, all the while partnering with other organizations to help implement best practices in public health and creatively figure out how to reach populations least-accessed by the traditional healthcare system.

Democratic Republic of Congo (DRC)

Hi Everyone,

Success! (= despite my technological ineptitude, I have finally been added as an author to this blog and will be able to post = thank you Lakshmi!).

To start with:

For those who have been wanting to hear about my time in the Democratic Republic of Congo this summer:

http://drcmrmd.wordpress.com/

(Disclaimer: I am not a very experienced blogger yet, and this blog is still a work in progress = even though I have been back in the US for over a month now, I am still mentally processing my experience in the DRC = so please leave feedback, your thoughts, etc. – I would love to hear them!).

Thanks everyone – I am definitely looking forward to being involved in some great exchanges on this blog this year!

Megan Rybarczyk, MSII

Running on hope

Just like Lakshmi (and, I am sure, many others), my summer research efforts came with a hefty dose of frustration. The lab samples I needed weren’t ready, there was no backup, everyone seemed to be on vacation, and, try as I might, I could not get across that, no, we couldn’t just put things off until tomorrow because I only had so many tomorrows left. A few days in, I was already panicking that my summer would be a waste, and nearly regretting not staying in Baltimore. With all the logistical, political and cultural issues that can make it so difficult to do global health work, why do we insist upon going halfway across the globe, not knowing whether our efforts will be worthwhile at all?

For me, the answer came, at least in part, towards the end of my stay in Morocco. My initial project was to run genotyping assays for a study of TB transmission, but as the obstacles piled up, I applied the first cardinal rule of global health: be flexible!!! I decided to devote my time instead to the logistics and patient recruitment aspects of the study and got the opportunity to meet with a group of migrants living in northern Morocco as they awaited an opportunity to cross the straits to Europe. They were the lucky ones. That very same week, 12 people had died of thirst in the desert, trying to reach northern Africa and a passage to Europe. Having lived an undeniably privileged life, one in which my daily worries and fears are pretty much limited to staying on the “P” side of Pass/Fail and taming my recurrent cravings for Chipotle, I could not imagine the depths of despair in which these men and women must be to take such tremendous risks, entrusting their lives to strangers and fate as they cross borders, deserts and seas.

The tragedy of the lives lost everyday in the deserts of North Africa and Central America, on the seas that separate Third World from First, reminds of just how important it is that we keep working towards better standards of living and human dignity for all, starting with better health. It is true that health is inextricably linked to issues of poverty, education, etc…, but it remains a critical starting point because of the powerful effects that it has on every aspect of the lives of people and societies; at its worst, disease not only debilitates the mind and the body, but also erodes the capacity for hope. When the death of relatives, friends, and colleagues become a fact of daily life, hope simply cannot be sustained, and neither can dignity. Societies in which disease and death abound will accord less value to human life loses its value, leading to the kind of social neglect, repression, and human rights violations that are the daily bread of so many in this world.

How, then, can we not justify going to the other end of the world and sparring with as many bureaucrats and corrupt officials as it takes to bring some measure of improvement? Bringing better health to every corner of the world is a daunting challenge and it may seem at times that we are fighting alone and for little reward, but it is a challenge well worth facing. For at the end of the road, lies the chance to restore not only health, but hope.

Water, Water Everywhere, Except Where There’s Disease

I spent the summer in India during the peak of monsoon, the rainy season. Everywhere I went were signs like, “know your Lepto,” or “how to identify dengue before it identifies you.” I jest, but seriously. The rains, anxiously awaited by millions across the subcontinent, represent growth, fertility, the harvest, and, unfortunately, disease.  In an economy that is as much agrarian as IT, and as dependent on weather as independent of time zone, monsoons are a blessing and a public health curse. Malaria incidence, too, was unprecedented this year, with public hospitals erecting overflow tents just to accommodate the hordes of patients flooding their grounds.

The flood has left 20 million homeless, and more than half a million suffering from waterborne and other diseases.

And this was just in areas of “normal,” seasonal rain. Imagine the situation in Pakistan. The floods have been catastrophic, not only for the devastation they have wrought, but also for the illness they bring. Diarrheal diseases have already claimed thousands of lives, and skin and respiratory illnesses follow closely. Waterborne diseases such as typhoid, jaundice, and diarrhea are particularly virulent, but higher incidence of H1N1 and other respiratory viruses also seems to be associated with the moist, cool climate.

As the situation in Pakistan evolves, it is increasingly clear that the flood’s chronic pathology will include large-scale infectious and health concerns, which must be addressed as urgently as any epidemic.