GHC Spring 2017 newsletter

Penn State Health

Global Health Center

Newsletter SPRING • 2017

IN THIS ISSUE

Welcome to our first-year Global Health Scholars – Class of 2020! Global Health Scholar students represent an astounding 25 percent of first year medical school classes. As part of the first-year requirements, this summer they will travel as small teams to seven different countries on four different continents.

Sharing public health experiences with peer organizations In March, public health graduate students shared their experiences and what they learned from their fourth-year trips abroad with their peers in public health programs.

At the 2017 Association of Schools and

Programs of Public Health’s (ASPPH) Annual Meeting, Penn State Master of Public Health students presented “Penn State’s Global Health Exchange Partnership: Reflections and Lessons Learned.” The poster presentation described the Global Health Exchange Partnership’s (GHEP) two-way educational opportunity for students to travel to international partner institutions, including sites in Taiwan, Ghana, and India. The GHEP also welcomes international students in the summer who travel to Penn State College of Medicine in Hershey to learn about the United States health care system.

Sharing resources enhances care in Western Panama With funds from an AFF grant, a borrowed ultrasound machine from the Penn State Simulation Laboratory, an auto-refractor from the University of Pittsburgh for eye examinations and an EKG machine and microscope from the Global Health office, thirty-one medical students, four nursing students and seven faculty of Penn State Medical Brigades enhanced the primary care services provided to more than 750 patients in Panama.

signs. Students at the lab station performed glucose, urine, and pregnancy checks; and skin scrapings for microscopic evaluations and EKGs with interpretations.

Upon arrival, the brigade visited a local health center, El Centro de Salud, in the mountains of West Panama. They were hosted by a family involved in organic farming, who also built an ecologically designed septic system.

“We are very appreciative of our Penn State Simulation lab for allowing us to borrow the ultrasound machine and for Dr. Dina Peralta-Reich for inviting her uncle, a Panamanian radiologist, to spend a day teaching us all,” said Dr. Eileen Hennrikus, professor at Penn State College of Medicine.

With the ultrasound machine and the expertise of a local Panamanian radiologist, students and faculty were able to scan thyroids, lymph nodes, arteries, veins, heart, lung, liver, kidney, fetuses, cysts, the optic nerve and more to screen for medical problems.

Patients then were seen by local and Penn State doctors with the students for physical exam and diagnosis. After deciding on a management plan, the students organized and distributed the prescribed medications and treatments with the Panamanian pharmacists.

During their seven-day trip in March, the brigade provided care in a mobile clinic in Nuevo Emperador, an urban community, and Santa Rita Abajo, a rural community. According to Global Brigades, Nuevo Emperador, with a population of 3,000, lacks consistent medical staffing at its clinic and does not have dental care. Santa Rita Abajo has a population of approximately 1,800.

Community volunteers collected patient information for electronic patient records. Students performed triage after recording the patients’ chief complaints and taking vital

In addition, the brigades created an eyeglass station to perform eye exams with the autorefractor and distributed more than 500 pairs of glasses. The auto-refractor was obtained through the efforts of second-year medical student Greg Williamson who taught students and faculty how to measure and label eyeglasses and match them to the findings of the vision exam and auto-refractor exam.

“The students found the appreciation of patients who could finally see and read to be unbelievably rewarding,” said Dr. Hennrikus.

To further round out their experience, the students assisted dentists in pulling teeth and in the application of fluoride to approximately 400 patients.

Charlas, the student run educational activities, were a huge success thanks

to the puppets provided by Dr. Linda Kanzleiter-Keister, Associate Professor of Family and Community Medicine, Penn State Health. Students provided interactive educational sessions to children and adults about the benefits of dental hygiene, nutrition and exercise.

The trip finished up in Panama City where the group received a tour with the Medical School Dean of the 1000 bed very busy Social Security Hospital and a signing of a Memorandum of Understanding between Penn State College of Medicine and the University of Panama Medical School.

Medical Brigades at Penn State is a chapter of Global Brigades, the world’s largest student-led global health and sustainable development organization. The Penn State chapter systematically works with more than 300 other university groups around the world to deliver and implement one of nine skill-based programs that benefit more than 130,000 Honduran and Panamanian, Ghanaian, and Nicaraguan community members annually. For more information about Penn State’s Medical Brigades, visit www.globalbrigades.org.

UPDATES

SPOTLIGHT: The Republic of Ghana The Republic of Ghana, located on the West Coast of Africa, holds the distinction of having the closest land settlement to the center of the world, the town of Tema, where the Equator and Greenwich Meridian meet at coordinate (0,0). In 1957, it gained its independence from Great Britain, the first sub-Saharan African country to do so. It’s one of the most thriving democracies in Africa, but it’s economy has been struggling recently. With a population of more than 27 million, 57 percent are below the age of 25.

The World Health Organization reports the top ten causes of death (as of 2012) are lower respiratory infections (bronchitis, pneumonia, pulmonary tuberculosis), stroke, malaria, ischemic heart disease (blocked blood vessels), HIV/AIDs, preterm birth complications, diarrheal diseases, birth asphyxia (lack of oxygen) and birth trauma, meningitis and protein-energy (diseases brought on by severe dietary protein deficiency).

Penn State Global Health Scholars have participated in service-learning trips to the Eastern Region of Ghana and its capital Koforidua, a city with a population of 2.6 million. It’s also the home of the Eastern Regional Hospital.

The focus of these partnerships in Ghana has been on community health and nutrition. Projects have included studying the reasons for and possible solutions to micronutrient disorders vitamin and mineral deficiencies such as Vitamins A, B and C, iodine, iron calcium and zinc which can have severe health consequences – in order to teach rural medical students about these disorders.

A new partnership between Penn State College of Medicine and MountCrest University College has allowed the expansion of the Global Health Scholar’s work in Ghana to include new teaching and clinical opportunities.

Volunteer clinical trips took place in early 2016 comprised of faculty, fourthyear medical students and residents to work with their peers to provide care and continuing education and to learn about the Ghanaian health system and the medical conditions most prevalent in rural Ghana. They provided care to the sick in the Emergency Room, on the wards and in the Operating Room.

In the Spring of 2017, pediatric faculty and residents worked with MountCrest University and at the Eastern Regional Hospital. See page four “Spotlight: Pediatric Care in Ghana” to learn more about the services they provided to the children of Ghana.

Statistical Profile - Comparison to U.S. Indicator

Ghana

U.S.

Birth Rate / 1,000 population (2016 est.)

30.8 births

12.5 births

Death rate/1,000 population (2016 est.)

7.1 deaths

8.2 deaths

Infant mortality Rate/1,000 live births (2016 est.)

36.3 deaths

5.8 deaths

Maternal Mortality Rate/100,000 live births (2015 est.)

319 deaths

14 deaths

Children Under Age 5 Underweight

11% (2014)

0.5% (2012)

Health Expenditures % of (2014)

3.6%

17.1%

Life Expectancy at Birth (2016 est.)

66.6 years

79.8 years

* All information was obtained from the CIA World Factbook and the World Health Organization

More than $22K Donated for Global Health Scholars Program Last November, Penn State College of Medicine participated in #Giving Tuesday – a national event to celebrate the power of giving back. The campaign raised $7,200 and a matching donor generously honored a full match of $15,000 for the Jeffries Family International Health Scholarship.

This scholarship provides financial support for students to travel to seven partner sites as part of the Global Health Scholars Program.

The Graduate Certificate in Global Health is now available.

The 12-credit curriculum provides an understanding of issues in global health, how global health systems interact and social, political and cultural determinants related to health and health systems. Find out more by contacting the Department of Public Health Sciences at 717-531-1502 or email pennstatepublichealth@phs.psu.edu.

Global Health Night Global Health Night was held on February 7 at the University Conference Center, raising funds for Church World Services of Lancaster which serves refugees and immigrants of central Pennsylvania. The event featured three guest speakers, along with poster presentations by students in the Global Health Scholars Program who had spent the previous summer performing their research abroad. Topics of the night included international medical disaster relief, health challenges of internally displaced people of Georgia, and refugee health care navigation.

SPOTLIGHT: Pediatric Care in Ghana In March, Dr. Haley Spagnola and four pediatric residents completed a servicelearning trip to Ghana to work with MountCrest University and to care for patients at Eastern Regional Hospital in Koforidua.

This was Dr. Spagnola’s second trip to Ghana. Last year she participated as a Penn State Children’s Hospital pediatric resident; this year she was the faculty advisor in her capacity as a pediatric hospitalist with Penn State Health St. Joseph.

Pediatric hospitalists focus solely on the care of hospitalized children and can modify treatment plans, follow up test results, and update family as new information becomes available. Most importantly, the pediatric hospitalists communicate with the child’s primary care physician and specialists to optimally coordinate care.

On this recent trip, they provided care to patients in the NICU/nursery or pediatrics ward daily. In the afternoon, they saw patients in the general pediatrics outpatient office or in the specialty clinic (asthma, low birth weight, HIV, sickle cell, neurology).

And on one Saturday, they conducted breast cancer screening outreach in a rural community in conjunction with a local organization.

Dr. Spagnola answered some questions for the newsletter about her experience in Ghana.

What was the facility like in comparison to what is available at Hershey Children’s Hospital?

The facility has several small buildings that house the “wards” or outpatient offices. Outpatient waiting rooms are outside with benches for patients and nurse’s station. The Pediatric ward is comprised of a long hallway with smaller wards that hold anywhere from 3 to 8 beds/cots. There was only one monitor for all of the patients. The NICU is comprised by 2 rooms filled

with bassinets and a few incubators side by side. Often there is more than one patient in an incubator or warmer. Again, there is only one or two monitors. In both places, the parents either sleep with the child in the bed or are sitting on a chair beside them.

How is the health care environment different in Ghana from the United States?

There is a national healthcare program that is cheap for people to enter.

However, there are still patient costs.

If a patient is hospitalized and needs a medication the family must go to the pharmacy and pay for it before the child can receive it. If a family cannot afford an evaluation (study/imaging) they will not get it. If a family cannot pay their medical bills upon leaving the hospital, a social worker will meet with them and set up a payment plan.

Medicine is more paternalistic in Ghana. There is no patient ownership of disease or involvement of patient/ families in decision making. There also continues to be denial of HIV/AIDS. Families often go to healers/prophets for medical care first, then when that fails they go to a doctor. Unfortunately, this is often too late.

Is there a need for the kind of care you provided?

I think that the most benefit the Ghanaians will receive from us is through education and implementation of new projects. We help with education in clinical management, but as we don’t provide a different service than already offered, our hands are tied due to limited resources in the same way the Ghanaian physicians are limited by resources available.

How did you enhance the education of the local health care providers?

We provided medical education in the form of didactic lectures. We also participated in bedside teaching with education/clinical reasoning during rounds.

We are working on implementing a discharge summary project. Currently there is no discharge process. In conjunction with the Ghanaian residents/physicians, we will implement a pre-survey directed at parents that gauges discharge readiness via understanding of follow up care, diagnosis, and medications. Then a discharge summary checklist will be implemented to ensure all patients receive discharge instructions both from the physician and nursing. This will help with continuity between hospitalization and future encounters.

Then a post-survey will be given to parents to see if the checklist improves parent/patient discharge readiness.

Why do you think it is important to provide this care in another country?

It is important to foster relationships between countries and to learn about other cultures. It is helpful for both parties involved since we are able to provide some resources while participating in the education of upcoming Ghanaian trainees. It is helpful for us to learn how to work in a limited resource setting and learn about tropical medicine/ global health.

What did you and your team learn from this experience? Personal and clinical lessons learned.

We learned how to work in a limited resource setting which also translates to better resource use in the US because we don’t use our resources in a costeffective manner. Also, we learned that they don’t see congenital hip dysplasia in Ghana, likely because they carry babies on their back and their hips are kept in an externally rotated position. The have a kangaroo mother care clinic (low birth weight clinic) that was only started a year ago. They discharge premature babies much earlier than in the US. By implementing this program which includes weighing, nutrition, education, and development assessments, they have had improved

Pediatric Care in Ghana continued mortality/morbidity. Through programs like this you can see how even when resources are limited, preventative care can make dramatic changes.

Is there something you would prefer the institution and department /residency program does to prepare you further for a trip such as the one to Ghana?

A formal global health training course would be helpful or other tips for working in a resource limited country.

Was there any cultural shock you experienced or a sense of helplessness, futility, emotional fatigue you felt?

Frustration – patients in America are unappreciative of the wealth of our country and care they receive. A very wide disparity exists between health care of the two countries.

Many of the Ghanaian children would not die if they had access to U.S. healthcare.

Fourth-year medical students return to Senegal Fourth-year Global Health Scholars had a rich cultural, clinical and professional experience on their monthlong return trip to Senegal.

Congratulations to Elise Mercier, Allison Weinstock, Evan Foley and Kristin Berger on completion of the four-year Global Health Scholars Program!

Global health in our own backyard Sitting at the dinner table in the home of Drs. Daniel and Therese Wolpaw, a recently resettled Syrian refugee family and Penn State College of Medicine colleagues shared more than a nutritious meal and an evening of music.

Last November, College of Medicine students reached out to three recently resettled Syrian families as part of their Food as Medicine initiative. Since then the number of families has grown to eleven, comprising approximately seventy people.

“The dinner, which is also a fundraiser, is one means of generating some income for Syrian refugee families who are struggling financially, although the bigger goal is to use these evenings as a cultural exchange to welcome them into their adoptive community,” said Dr. Daniel George, associate professor of humanities at Penn State College of Medicine.

Through Food as Medicine’s flagship program, Prevention Produce, their primary activity takes place every Friday when they drive families to the Broad Street Market in Harrisburg to help them purchase fresh fruits and vegetables.

However, they’ve done more than focus on healthy eating.

They’ve been instrumental in raising funds and collecting donations of clothing, toiletries, diapers, cleaning products, and furniture, and raising awareness among their colleagues.

“The families often invite us back to their homes around the market and deep relationships have developed. We have learned about other acute needs (language training, medical conditions, employment, etc.) and have tried to help the families out in these areas as we are able,” said George, who has served as adviser to the Food as Medicine Group since its inception in 2010.

If you are interested in donating clothes, household supplies, or other resources, please contact Dr. George at drg21@psu.edu.

To support the purchase of fruits and vegetables, visit: www.tfec.org/prevention-produce.

REFLECTIONS OF MEDICAL STUDENTS: Saving a Life, Facing the Realities of Death Jill Parsons, Class of 2017 Since my very first trip to Zimbabwe back in 2010, I had struggled with my purpose in global health. Each trip had been challenging and ultimately not enjoyable, and I had questioned whether I should continue in global health. However, leading up to my trip to Zambia, I had a sense that this trip would change everything because I would finally be doing medicine abroad – what I had dreamed of since I first became interested in medicine. This trip would represent the very reason I went into medicine – to serve the underserved. And the trip was just that and more.

One experience in Macha stands out above the rest. I befriended a Canadian nurse named Amanda. She works on the pediatric ward, so I would often see her there. When we were hanging together one evening, we were discussing some of our experiences and some interesting cases.

She mentioned a baby named Samuel, who had come in with fever, altered mental status, and seizures that progressed to status epilepticus a few times. Amanda mentioned her concern that medical officers didn’t know what was going on with Samuel, so they were treating him for sepsis, meningitis, and cerebral malaria.

The following day, I went into the pediatric ward to examine this baby.

Because of my excellent training from Penn State, my very first thought was that he had viral encephalitis. I shared this with the medical officer and he agreed that this could be a possibility and to proceed with treatment.

I stopped by the pharmacy to see if intravenous acyclovir was available, but all they had was oral acyclovir. I

discussed this with Drs. Spurrier and Thuma, who encouraged me to try oral acyclovir, even without the evidence that oral acyclovir can penetrate the bloodbrain barrier. With their assistance, I dosed the acyclovir as we would with the IV form to treat HSV encephalitis, in hopes that this may overcome the absorption barriers.

I checked on him daily and, slowly, over the course of the next three weeks, Samuel recovered! When his recovery was expected, a few of the physicians congratulated me on the call of viral encephalitis.

I discovered that avoiding resuscitation efforts is sometimes actually an act of mercy for patients.

I was forced to confront the reality that in this environment, even if you are able to resuscitate a patient, what would be next for them? They don’t have access to the basic medical equipment required to keep them alive or comfortable, and they would likely suffer more in the aftermath. In Zambia, death had a very different connotation than what we’re used to in the States. There wasn’t any blame placed on the physician for the patient’s death. It is just accepted that death is a normal part of life. I

Through this experience with baby Samuel, I learned a lot about medical missions. First, that “I learned a lot about medical even though there are missions…even though there are limited resources, you still try whatever you limited resources, you still try can, sometimes even whatever you can, sometimes despite the medical even despite the medical evidence.

Second, every patient is worth evidence.” the time, effort, and emotional energy you invest in them. was humbled by this cultural view of While the story of baby Samuel had a death and found it refreshing that the happy ending, I also had the unfortunate physician can receive such grace from experience of many patient deaths patients and their families in light of during my rotation. There were many such a tragedy. deaths that infuriated us due to the perceived simplicity of resuscitating and These examples only begin to scratch the helping these patients, but this is also surface of the life-changing experiences a necessary component in the life of a I had while in Macha. It suffices to say that I now have a new perspective missionary doctor. on medicine and missions. I am now Through the attending doctors I had the considering long-term missions as an chance to work with, I had to learn the option for my future in medicine. The hard lesson of medical missions – that thought of long term-missions used to you do whatever you can, and let go of terrify me. But now, because of this trip, the lives that you are unable to save due I wait in anticipation of what is yet to to the limited resources you have. While come for my future in medical missions. this initially looked like laziness to me,

REFLECTIONS OF MEDICAL STUDENTS: Building community relations through eye care and beds Kelsie Herring, Class of 2017 One reason for gravitating toward Penn State was the longitudinal Global Health Scholars Program (GHSP). By returning to the same site in the fourth year I was able to not only see how the region looked after four years, but also to reflect on how I had grown over that same time period both professionally and personally. Having the opportunity to help create the GHSP Zumbahua, Ecuador site, I felt an even greater responsibility in collaborating with the people there.

This year, I was fortunate to receive the Stratton Scholarship. With the help of the Strattons, who are extremely amazing benefactors, we were able to do three major things: connect a rural community to a cost-effective eye clinic, continue to build community relationships with the public health clinic and privately run hospital for future students, and donate 10 beds and mattresses to benefit workers and families in need in the communities surrounding Zumbahua.

Many people in the community have eye problems such as corneal abrasions, cataracts, and pterygiums which limit their quality of living and ability to work in an agricultural lifestyle. We worked to connect the community to a nearby eye clinic which offers cost-conscientious care to the rural indigenous farm workers. We traveled to individual homes to conduct initial histories and successfully took three people to get eye exams and learn about treatment options.

A 71-year-old man, nearly blind with cataracts, lives and works in the rough terrain of the Andes mountains at about 13,000 feet elevation. Years prior he was told he needed surgery, but that it would cost $900, an outrageous amount of money since he didn’t even have the $8 for the exam and travel to the clinic. Together we met with the clinic and his family, and proudly, with the help of family, he

is planning on having the surgery there; what a huge quality of life change!

Another story I can’t forget is the hike that I took, past open fields, alpacas, and a pack of vicious dogs, in search of a woman who had “eye problems.” That’s all I knew.

I had no idea what I was getting into, but we hoped that it was another good case for our collaborating eye clinic. When I finally found the woman, I pulled out the only medical eye equipment that I had carried: my history taking skills and a keychain light. Though our native languages are English or Kichwa, we communicated in Spanish, our common ground. And can I tell you how exciting it is as a medical student to be able to use your history and exam skills, and confidently say to yourself “Yep. This is a pterygium!” What a long way from afternoon clinical skills sessions in the PBL classrooms! I then explained the process and arranged a meeting time to go with the woman to the eye clinic for a more in-depth evaluation and explanation of treatment options.

Additionally, we met with community leaders and school teachers to set up health education classes. We used the Health SLAM materials (created by a PSUCOM alumnus) to teach healthy eating in a local school and joined with a team from the public health clinic to visit other surrounding community schools to teach about general hygiene, dental hygiene, and proper food health. What amazing outreach!

to the Casa de Niños who advised the best use would be to distribute them to the houses of families in need.

One set of beds went to a family of 10 children; the mother died after the birth of the youngest child. The two oldest kids are married and independent but the other eight stayed with a relative, in ONE bed. By donating the bunk bed to their two room cement and dirt house, you can imagine the change for those children as they grow. The Italian run hospital also has an outreach group that builds houses for families in need. We helped construct the cement floor for the new house, in which another bed will be placed when the house is completed. (And what a great workout to hand-mix cement; I loved working with and learning from the local contractors!) Another bunk bed went to a family of eight, high in the Andes mountains where it is often cold, rainy, and wet, in a one-room cement and dirt house with gas stovetop and open fire which served as a kitchen. Off to the side of the stove was the parents’ bed and a bed frame with straw covering where the six children slept together. All recipients were very grateful for the bunk beds.

From working out the details of our projects, exchanging laughter and languages with my homestay family, running down volcanoes, hiking under waterfalls, and swimming in natural hot springs, GHSP Ecuador has been a rewarding experience. I look forward to hearing about the adventures of future students!

The bunk beds were constructed by a local carpenter, another way to give back to the community. One “And can I tell you how exciting it is as bunk bed will be a medical student to be able to use your used by volunteer history and exam skills, and confidently doctors and nurses say to yourself “Yep. This is a pterygium!” that run the What a long way from afternoon clinical hospital. Additional beds were donated skills sessions in the PBL classrooms!”

MPH STUDENT SPOTLIGHT: Evaluating antibiotic resistant bacteria in Taiwan Bacterial resistance to antibiotics is an increasing problem in the world today. Megan Litz, a second-year public health graduate student, traveled to Taiwan last summer as part of the Global Health Scholars Program to study the efficacy of probiotics on a particular strain of antibiotic resistant bacteria – enterococci, a normally occurring bacteria in our gastrointestinal system.

This bacterium may cause an infection if it gets into our blood, wounds or urine, especially in sick people.

“During my time in Taiwan, I completed a systematic review and meta-analysis of clinical studies that assessed the efficacy of probiotics on vancomycin [an antibiotic]-resistant enterococci with the purpose of helping Taipei Medical University develop parameters for their own clinical trial,” explained Litz.

“I presented the results to TMU’s Infection Control Unit and Translational Medicine Lab,” said Litz. “We found that randomized controlled trials using the probiotic Lactobacillus rhamnosus GG appeared to have a strong effect on the decolonization of vancomycin-resistant enterococci (VRE) in clinical patients.”

In particular, administration in the form of commercially available yogurt had the strongest effect (OR=44.000, 95% CI 3.966, 488.188) compared to it being given in a supplemental form dissolved in milk or water (OR=5.238, 95% CI=1.724, 15.919). However, it is of note that only a small number of blinded randomized controlled trials assessing the efficacy of probiotics on the decolonization of VRE have been performed.

Of the original seven studies included in the review, only

Contact and Support Information: For more information, contact Brian Bennett, MEd., Manager, Global Health Center at bbennett1@ pennstatehealth.psu.edu or by calling 717.531.0003 x284454.

Visit our website at med.psu.edu/global-health Consider a Gift Today to the Global Health Center Scholarship program! Checks may be sent to:

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Contact Devon Johnson to set up your own scholarship at ddominickjohnson@hmc.psu.edu.

two warranted being included in the final analysis. The small number of studies included in the meta-analysis is a major limitation in the study. Additional vigorous randomized controlled trials should be performed to investigate the effects of probiotics in decolonizing VRE and bolster the credibility of further meta-analysis.

Litz had the opportunity to collaborate and engage with experts in the infectious disease field, both on the clinical and public health side.

“I had the opportunity to learn about the ways in which the structure of the Taiwanese healthcare system influences health outcomes.

“This experience made me want to be the type of public health professional who encourages multifaceted collaboration and who always asks more questions than gives answers. I hope to make a positive change in the U.S. healthcare system by practicing with Taiwan’s forward thinking, adaptable attitude”.