Marjory Bravard, Mbarara, Uganda, Technology in Global Health Exploration II

Let�s talk a little bit about leapfrogging and global health technology.  The basic idea of leapfrogging is going from an underdeveloped state to a modern one without going through the historical intermediate steps.  A good discussion of leapfrogging technology can be found here.  The classic example is cellphones: countries going from few landlines to many people with cellphones, skipping over the slow creep of landline networks throughout the land.

The first great leapfrog project in global health I heard of was at Fogarty orientation a few years ago, when Krista Pfaendler spoke about her work in Zambia in cervical cancer (1 and 2).  At the time Zambia had one of the world�s highest incidence of cervical cancer, and only one pathologist who could read pap smears.  Obviously a pap-smear based screening program would not work.  This project leveraged the relative abundance of nurses and midwives relative to doctors to allow screening for cervical cancer using visual inspection with acetic acid.  A cheap digital camera is used by the nurses/midwives in the screening to ensure quality control and for assistance with clinical decision making and triage, with the assistance of an attending gynecologist.  What most impressed me about this project was the ability of a cheap digital camera to leverage the assets of a developing world health setting - nurses and midwives � to reach patients with useful interventions.  In 2.5 years the program was able to screen 20,000 women for cervical cancer in a country with a very high incidence of cervical cancer where there was previously no real screening program.  I�m incredibly impressed!  I think this is an excellent demonstration of the global health technology that works.  

While in Mbarara I checked out a few global health technology projects.  One is the UARTO study, which monitors treatment adherence in HAART treatment for HIV.  The study currently uses a device called Wisepill

to monitor treatment adherence.  Wisepill is a digital pillbox that sends a signal through the cellphone networks every time it is accessed.  If no signal is received by the study center for 48 hours, that is considered a treatment interruption and a field team goes out to see if it is a wisepill problem or if the person has stopped taking their meds, and why.  I went on an interruption visit one day (photo at left).  One of the participants we visited only needed a new battery for his wisepill, another had stopped for unclear reasons since her husband had been released from prison, and a 3^rd wasn�t home when we visited.  I think it�s an excellent approach to monitoring and helping with treatment adherence, and again one that uses technology to optimally use human resources.

In many parts of the world travelling to clinic to get results of tests costs a lot: both literally and in terms of opportunity cost with missed work. There is clearly tremendous potential to use cellphone networks to deliver test results in these settings.  Dr. Mark Siedner and I sat down to talk about a project he is developing to look at the feasibility and acceptability of delivering testing results via mobile phone.   Given issues of confidentiality and follow up treatment or testing it will be interesting to see where the project goes.  This is an under-developed area with a lot of potential.

Technology can be also used in decision aids.  Dr. Data Santorino, a Ugandan pediatrician, and I sat down to talk about a project he runs which uses smart phones to guide village health workers through algorithms for clinical decision making for treating and triaging sick children.  In this way, community volunteers with a few hours of training can used symptoms-based algorithms to treat common diseases like pneumonia and malaria, and refer to a health center when appropriate.  The data is reviewed by Dr. Santorino in the referral hospital at which time he can contact the village health worker to follow up or change triage decisions where appropriate.

Global health technology does not have to mean the fanciest new device that can detect x disease with 100% sensitivity and specificity.  To me it means the utilization of appropriate technology to leverage local assets in a way that benefits the local population in a cost-effective manner.  A development technology example I love is sanitary napkins to keep girls in school.  Educated women and their children have better health outcomes, and this is an incredibly simple way to impact school attendance.

My excitement about global health technology is its potential to help with resource allocation, clinical decision making, training, and development to be able to multiply the effect of people working hard to improve the health and lives of those in their own communities.  I leave you with a great website on global health devices to whet your appetite for the future ...

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Marjory Bravard, Mbarara, Uganda, Technology in Global Health Exploration

I am a 2nd year resident in internal medicine from MGH and just spent one month in Mbarara, Uganda learning about ongoing technology research projects and working on the medical wards.  Happily, I have just received word that I was awarded a Center for Global Health Travel grant to help fund this work.  I would like to use this forum to write a bit about the setting and explore existing technology projects and some ideas for the future of global health technology.

Mbarara (at left) is a town of about 87,000 in western Uganda.  It is located only about 2 hours drive from the equator, but is at an altitude of about 1400 meters and so the climate is rather mild, although the sun is, as expected, quite hot.  Also as a result of the altitude, malaria is less of a problem here than in many lower-lying areas.  This is notable given that in Uganda, malaria is the number one cause of morbidity and mortality.  

Here are some sobering malaria statistics for Uganda (see links 1 and 2 for more):

-       cause of 25-40% of outpatient visits, 15-20% of hospital admissions, 9-14% of hospital deaths

- number of malaria deaths /100,000 population (2008): 103... Just to emphasize, that�s 1/1,000 each year

- percentage of households with greater than 1 mosquito net: 34%

- percentage of insecticide treated net coverage: 12.8%

Malaria is so ubiquitous, in fact, that in Ugandan English, the word �malaria� is used to denote fever.  With limited diagnostics, in fact, one often is equivalent to the other.  By this I mean, when in doubt, fever is treated with antimalarials (and often ceftriaxone if there is concern for bacterial sepsis) until paristemia results can be obtained.   I sat down and spoke with Margarita Riera Montes, director of the MSF Epicenter in Mbarara, to talk a little bit about their malaria work.  They are doing some studies looking at malaria heterogeneity across a small geographic area (village to village) and also looking at the use of inhaled nitric oxide as an adjunctive treatment in cerebral malaria.  Fascinating stuff � I can�t wait to see the results.

But where does technology fit in, you ask?  Well one interesting missing piece is bednet adherence.  While insecticide-treated bednets are really the core of malaria prevention (see links 1 and 2), there are no good studies that objectively look at utilization, since all studies have been done with bednet use self-reported by study participants.   So Paul Krezanoski, a co-resident of mine at MGH, is working with Data Santorino, a Ugandan pediatrician, on building a bednet monitoring device as part of a study to look at actual bednet utilization: when it is used, by which family members, and crucially, when it is not used.  This information would be critical to really gauge how best  to improve bednet utilization and also to give real data to parents on how to prevent malaria in their children.  For example, how many nights under a bednet prevent one case of malaria (number needed to treat)?  I�m very excited about this work.  It's very powerful to be able to get at the truth of utilization of bed net technology... and in the future be able to assess the impact of interventions to improve utilization.

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Disability and Global Health Equity: The Call to Action (Entry 3/3)

Cheri Blauwet, MD

PGY-3, Physical Medicine and Rehabilitation

St. Marc, Haiti

Comprehensive Rehabilitation Program - Zanmi Lasante/Partners In Health

As my month in Haiti is now nearly complete, I am compelled to write about my perspective of disability as a component of global health equity. Although this concept has previously been outlined and discussed within the global discourse of health as a human right, it deserves further emphasis given that disability, unlike many aspects of chronic or infectious disease, is often overlooked within health and health care-related advocacy efforts. 

I will start with the basic facts. It is estimated via the World Health Survey of 2002-2004 that approximately 15%-20% of the global population are individuals with a disability. This figure includes those with �significant difficulty with functioning in everyday life,� and can include those with traditionally defined disability such as amputation, stroke, spinal cord injury, brain injury, etc., however also include those with disability related to chronic disease or mental illness. The prevalence of disability also increases acutely at times of natural disaster or domestic and international conflict. It is commonly accepted that individuals with disabilities remain one of our most vulnerable populations globally. As often stated in disability and
international development initiatives, �disability is both a cause and consequence of poverty.� ¹

If I hadn�t already believed this to be true, my time in Haiti certainly offered unequivocal confirmation of this theme. As initially described in Entry #2, our Rehabilitation Team continued to engage in home visits in keeping with the ZL/PIH �accompagnateur� model. With this, patients work closely with a local community health worker to create sustainable, culturally-appropriate system of medical and psychosocial support. Our Team visited patients of various backgrounds and complex needs, to include amputees (both traumatic and vascular), those who had experienced strokes, a gentleman with incomplete C2 spinal cord injury as the result of Potts, a man who had experienced tabes dorsalis as a component of tertiary syphilis, and several others. As expected, our patients had extensive rehabilitation needs such as impairments in mobility, range of motion, activities of daily living, cognition, and poorly-controlled pain. Even more striking, however, was the invariable context of extreme economic insecurity in which they all lived. Subject to difficult circumstances simply due to disability, many were also abandoned by spouses and family as the result of physical and functional limitations. Parents with disabilities were often left to raise their children alone and without a reliable source of income. Likely due to stigma, almost none were able to hold employment or vocation, leading to even greater resource insecurity and reliance on extended family members or neighbors in the community. In addition to physical or cognitive disability, many also experienced poor health due to medical conditions such as poorly-controlled hypertension and diabetes. Most were at high risk for abuse and neglect.

Given this context, it is our priority to promote psychosocial empowerment while also providing medical rehabilitative care. As a capstone of my experience and acting as an illustration of this, our team co-sponsored an event in Port au Prince focused on disability advocacy and inclusion. With this, we wished to create an environment of celebration through which people with disabilities came together to promote community. The event was titled �Respect Me,� and pocket cards as well as posters of this slogan were distributed both in English and Creole. The phrase �Respect Me� was then used as an acronym to emphasize the concepts of: respect for dignity, empowerment, support autonomy, participation, equality of opportunity, communication, tasks of daily living, mobility, and environmental accessibility. We were honored to have the presence of Gerard Oriol, the Haitian Secretary of State for the Inclusion of People with Disabilities. All in all, it was a tremendous success and a call to action for us all � physicians, advocates, leaders, followers, people with disabilities, and their colleagues/friends.

I continue to stand by the notion that an empowerment and self-respect are the cornerstone of promoting both health and health care for people with disabilities in Haiti. With this in mind, there is much more work to be done. That said, we can also enjoy and be proud of how far we have come. It is my hope that those who attended our event can carry the phrase of �Respect Me� in the front of their minds, and use it when societal barriers hold them back from achieving true health. 

¹ �Disability, Poverty and Development.� A thematic report from the UK Department for International Development (DFID). February 2000.

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Cholera in Bangaldesh introduction, Ana Weil, Internal Medicine MGH 2

           The International Centre for Diarrheal Disease Research, Bangladesh (icddr, b) where I am working in cholera is a research center and hospital in Dhaka, unique because of the commitment of those who work there to savings lives through both clinical care and research. Known in Dhaka as the �cholera hospital� or �diarrhea hospital�, admission to the hospital requires diarrhea (except in HIV patients). During cholera season two times a year, up to a thousand patients per day can present at the hospital for treatment; during these times, tents for makeshift cholera wards are assembled in the parking lots. Cholera cots, or wooden cots lined with plastic sheeting with holes in the middle for stool collection and measurement of fluid losses, appear in every corner of the hospital.

           

            The staff at the icddr, b knows that if a patient arrives to the hospital breathing, death can be avoided. Even if a pulse is absent, an IV is placed and rehydration is initiated. The speed at which this treatment begins is incredible; I have seen large-bore IVs placed in an unconscious patient still in the doorway in the arms of a family member. The nurses and IV teams at the hospital know how important speed is; they are empowered to save lives and go to great extents to do so. They are the world�s experts in treating cholera. Medical staff from the icddr, b has traveled to every major cholera outbreak in the world in the last decade to train local staff. Because the amount of rehydration required in cholera is much more than used in other diarrheal diseases, inexperienced staff can inadvertently under resuscitate patients and death can result. Research studies have documented the decrease in case-fatality rate that occurs after an icddr, b team arrives at the site of a cholera outbreak.

            Oral rehydration solution was first used in Bangladesh during a cholera outbreak in the 1970s. This simple mixture of clean water, sugar and salt is one of the most important medical discoveries of the 21^st century, and has saved millions of lives. For several decades, the icddr, b and other sites in Bangladesh have been leaders in research and clinical care of patients with diarrheal disease.

            More recently, the icddr, b has changed HIV care in Bangladesh. HIV is thought to be rare in Bangladesh, and the prevalence of disease is not known. The icddr, b is the only hospital in the country with an HIV ward with care specifically for HIV patients and their families. During my month in Dhaka I was able to join in on rounds during my time out of the lab, and also took part in teaching medical residents working in the HIV ward.

           

            For more than a decade the icddr, b and MGH have collaborated to study the immune responses to cholera with an aim to improve cholera vaccines. After cholera, patients are protected from severe disease for at least several years through immune mechanisms that are not well understood. We believe that anamnestic memory responses in the gut confer protection, and T cells may have a role in the creation or maintenance of this response. When a person is diagnosed with cholera at the icddr,b, a large field team in Dhaka enrolls patients and their household contacts in the immunology studies at the time of hospitalization for cholera. In the lab, we receive blood from the patient on day 2 of their hospitalization (usually also the day of discharge) after their stool culture grew Vibrio cholerae overnight. With fresh blood, PBMCs are extracted for B cell studies and whole blood is prepared for flow cytometry examination. During the next year, this same patient and their household contacts with have blood drawn several times, and field workers will visit their homes to ask them about any symptoms they have and send them back to the icddr, b for severe illness. My immunology work is focused on T cell responses to acute cholera infection, and utilizes unique techniques in preparation of whole blood for flow cytometry.

            During medical school I worked at the icddr,b for one year, and made lifelong friendships with my colleages in the lab at the iccdr,b. Together we stayed late in the lab, came in on weekends, and spent hours troubleshooting the flow cytometer. It was wonderful to return to the lab and continue this work, see old friends, and spend time in this colorful city. The relationship between the icddr, b and the community allow work in cholera immunology to enter a second decade, and I hope to continue to be part of this work because of both the importance of the science and the wonderful people I have had the privilege of working with.  

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Cholera in Bangaldesh introduction, Ana Weil, Internal Medicine MGH

           I am a 2^nd year medicine resident from MGH spending one month in Dhaka, Bangladesh to work in an immunology lab studying responses to cholera. I received a Center for Global Health Travel grant to pursue this work, and in these blogs will introduce the topic of cholera with a few details about the research I am doing and the institution where this research is conducted. 

            In Bangladesh, the most densely populated country in the world, the capitol city of Dhaka contains at least 15 million residents, many of whom live in urban slums. Dhaka is a colorful and chaotic city, and every day thousands of people come to Dhaka from the countryside of Bangladesh in search of a better life. Nearly all cholera patients come from the urban slums, particularly one called Mirpur. This slum contains around 3 million people living in shacks and makeshift residences, and the water supply is heavily manipulated by people tapping in water lines illegally. This manipulation leads to sewage lines mixing with the water supply. Most people do not boil or treat their water prior to using it, since fuel for a fire and water treatment supplies cost money. In Dhaka, diarrhea is a common and somewhat normalized fact of life for both visitors and the Bengali people, especially children. The usual causes are E coli spp as well as rotavirus, shigella, typhoid and other bacterial, fungal and viral causes, in addition to cholera.

            Cholera occurs in areas of the world where the 20^th century innovations of clean water and latrine use are not yet realized. There are 3-5 million cases of cholera each year and most cases are in southeast Asia. Children are disproportionately affected. The organism that causes cholera, Vibrio cholerae, lives in the environment in the Ganges Delta, which is the largest river delta in the world. This flat, easily flooded plain includes much of Bengal in northeastern India, as well as Bangladesh. This area has supported large populations for thousands of years, and for centuries cholera has caused disease both year round and in epidemic spikes during the two rainy seasons each year. V. cholerae is spread by fecal-oral transmission and causes a range of disease from asymptomatic or subclinical infection to severe dehydrating diarrhea that can cause death within 6-12 hours if untreated. In this short time, patients can lose more than 10% of their body weight in fluid losses, and adults can loose 20 liters or more. The primary treatment is rehydration, and in most patients oral rehydration is sufficient. In cases accompanied by severe vomiting, or dehydration that progresses to depressed consciousness, intravenous rehydration is required. Antibiotic treatment decreases the severity of disease and shortens the duration of symptoms. In Dhaka, tens of thousands of cases of cholera occur each year.

            There are several vaccines for cholera, and these have improved significantly in the last several years. They provide partial protection for several years, but are not very effective in children. My work in immunology is focused on understanding the immune response to natural cholera infection, in an effort to understand what creates the longer-lasting immunity we see after natural infection versus the partial, shorter-lasting protection observed after vaccination.

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Rehabilitation - from A to Z

Cheri Blauwet, MD
PGY-3, Physical Medicine and Rehabilitation

St. Marc, Haiti
Comprehensive Rehabilitation Program - Zanmi Lasante/Partners In Health

I am now one week into my rotation in Global Health/Physical Medicine and Rehabilitation with the Zanmi Lasante Rehabilitation Team and in partnership with my residency program at Spaulding Rehabilitation Hospital. In considering the lessons most poignantly learned over the past 7 days, the ability to care for spinal cord injury (SCI) patients through the continuum of their care remains a highlight of my experience thus far.

Last Saturday our colleague from the Emergency Department called to ask if we could come see a patient for lower extremity parasthesias/weakness after involvement in a motor vehicle accident. It had already been approximately 12 hours since the time of injury, however his exam was clearly consistent with spinal cord injury at approximately the L2/L3 level, to include a palpable step-off sign as well as the flaccidity and decreased reflexes associated with spinal shock. The next several hours involved no less than 50 calls to surgical facilities throughout Haiti in an attempt to obtain the appropriate neurosurgical management for his acute SCI. He was ultimately transported to Port au Prince and admitted to a facility with the capacity for CT imaging as well as surgical management. There, he was diagnosed with an L2 burst fracture and in most recent discussion, he remains on strict spinal precautions while awaiting surgical decompression/fusion until a neurosurgeon is available within the next few days.

Only a few days later, I had the opportunity to go on home visits to see spinal cord injury patients within the Artibonite region and to more fully understand the manner in which care can be provided in the community. Observing the work of the St. Boniface Hospital Rehabilitation Team (a organization whose mission is closely aligned with our own), I was exceptionally impressed with the commitment and resourcefulness that enabled individuals with SCI to live full, healthy lives in their own home environments as opposed to within institutions. To provide an example, we visited one woman with a C7 SCI (and therefore tetraplegia) who was discharged from the inpatient setting only 2 months ago. Immediately after her SCI, she had developed Stage IV decubitus ulcers prior to receiving appropriate care, and these were still in various stages of healing. The Team had contracted with a layperson in the community for purpose of dressing changes two times a day given the lack of hands-on nursing care in her rural community. A cadre of �community integration technicians� had visited her home and widened the doorway of her small, brick home in order to allow her wheelchair to enter. The Rehabilitation Team had brought a small but reasonable monthly supply of supplies not available in her community, such as urinary catheters, wound care supplies, and medications frequently useful to the SCI population such as Gabapentin for neuropathic pain. In this setting, she was doing quite well and appeared to be moving forward, both physically and emotionally, despite having a diagnosis that would likely have been considered end-stage only a few years ago prior to the implementation of community based rehabilitation.

                         On a home visit near Verrettes, Haiti (permission given to post)

                           An example of home modifications (door widened, sidewalk from 

                                        street created with small ramp into home)

This series of events brought home to me the possibilities inherent within the process of rehabilitation, from managing high acuity injuries to ultimately considering issues of community reintegration as a portion of our role as physiatrists. This true continuum of care is what heavily attracted me to this field, and it is what keeps me �hooked� at the end of the day. 

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