N EWS
Winter 2015
Global Health
CONTEMPLATION • COMPASSION • ADVOCACY
Dr. Timothy Craig Visits Vietnam Professor of Medicine and Pediatrics, Distinguished Educator This was my eighth trip to Vietnam. Vietnam, with a population of 90 million people, is a country of vast contrast, beauty, culture and uniqueness. Following the Vietnamese War, there was a period of isolation. These past 2 decades have seen Vietnam reopen itself to the world. It entered the World Trade Organization in 2007 and by 2011 had one of the fastest global growth rates in the world. During this rapid expansion health care has lagged and there is a shortage of health care providers, hospitals and hospital beds. In the near past less than 1% of GNP was spent on health care and the present number is 3%. Malaria is still present; however, Vietnam has been successful at reducing its incidence. A growth in the number of cases of TB and HIV are the present focus of health care agencies throughout the country. Most health care is paid for in cash, but there is increasing private insurance and federal coverage. However, this need to pay cash has led to significant health care disparity, especially when the average salary is 150 USD a month. Being under staffed, lacking facilities and having large disparities has required doctors to see large number of patients and hospital beds at times have more than one patient. Pediatric Hospital Number 2 in HCMC has over 1200 patients and treats up to 5000 patients a day and a ENT surgeon at the ENT Hospital in HCMC may see 60 or more patients a day. What is very difficult to believe is that the average doctor makes only 250 USD a month and some as little as 150 USD, which requires most to work in private clinics in addition to their government funded positions. Despite these intense demands, I continue to be overwhelmed by the quality of the physicians’ care and their interest in the continuing acquisition of knowledge. I do not go to Vietnam to see patients; I go to teach and develop quality assurance projects. The main barrier to teaching in Vietnam is the lack of English speakers, the result of the period of isolation following the war. Older physicians in the north may know French and in the south the older physicians often know English. Few middle age or young physicians know English. They realize this is a large disadvantage for them to enter the world “screen” in medicine and I truly believe that
is why people are excited to work with American doctors. I have been extremely fortunate to have had the opportunity to develop a network of colleagues in Vietnam. It began when I found an internet article highlighting the “Vietnam Education Foundation”, which is a USA Federal Grant program similar to the Fulbright Program. I wanted to apply for this grant and thus I packed my bags and went to Vietnam, knocking on doors to determine what was needed. This effort proved successful. I was awarded a VEF grant, which brought me to Hanoi, where I collaborated with the Allergy Immunology and the Respiratory groups. I provided a series of lectures at the Lung Hospital in Hanoi. I reviewed skin testing protocols, spirometry protocols, mentored a PhD student and gave a lecture series. At the Allergy Immunology Center we were successful in our research endeavors and presented abstracts at our national professional organization and some international organizations. Manuscripts were also accepted for publication as a direct result of this collaboration. I helped establish an allergy clinic at the ENT Hospital in HCMC. At this hospital, I also mentored a Master student, leading to the publication of abstracts and ultimately his degree, and established skin testing in Pediatric Hospital #2 in HCMC. More recently I have been working with the Vietnam Respiratory Society and the Medical University in HCMC to try to develop safety and quality assurance projects in the University’s satellite respiratory screening centers. I am hoping to be refunded by VEF for this endeavor; however, obtaining a second VEF grant is very difficult. This project is extremely important since with urbanization the asthma prevalence will increase, with industrialization occupational exposures and associated lung diseases will increase and cigarette smoking is rapidly expanding and with it COPD. Add to this the high prevalence of TB and it should be obvious that the need to ensure proper hygiene and technique for identifying and treating respiratory patients is important. This has been one of the highlights of my life. The research opportunities in Vietnam are vast. The transition from rural to urban and from agriculture to industry makes asthma a key disease and it is these exact variables that changes the prevalence of asthma from less than 3% to greater than 10% because of reasons we fail to understand. This is a living laboratory ripe for research. If you have ideas you wish to pursue please reach out and would be honored to link you into my network of friends and colleagues in Vietnam. To Life, Tim
A Brief Description of Medicine in Australia By Dr. Efren Rael Australia has what would be best described as a universal health care system. The system called Medicare is available to all Australian citizens, regardless of employment or income status. Australian Medicare is funded with a 1.5% levy placed on all income earned (with the exception of low income earners) and in conjunction with the Australian government from general revenue. There are two types of medical services provided in Australia, the most common is what is referred to as the “public system” and the other the “private system”. As previously mentioned the first is available to all and the second is available to those who pay for “private health coverage”. The “private system” will allow a patient to choose their provider and not have to wait for elective procedures. In the “public system” patients will be seen by the doctors that are available in the private clinics or hospitals and are placed on a waiting list for any elective surgery. Higher income earners are encouraged to take our private health care and if they choose not to are charged an extra 1% levy on their earnings. Any Australian can see a GP (General Practitioner) for any medical issue. If a specialist visit is required this can only be arranged by the patients GP, a patient cannot arrange an appointment directly with a specialist and will only been seen by a specialist when a referral is received from the GP. The GP acts as a gatekeeper to specialist providers. As well as Medicare there is what is referred to as Pharmaceutical Benefits Scheme, the PBS considerably subsidies a range of prescription medications. The government pays for most of the medical costs in Australia. There are, in some cases out of pocket expenses unless a provider chooses to “bulk bill” (charging only the scheduled fee). This can apply to both GP and specialist services. Australia is considered to have a very high level of medical care and generally speaking it’s citizens are happy with the care provided and way the system operates.
Welcome to Kristin Sznajder, Ph.D. Assistant Professor and Associate Director of International Initiatives for MPH Program
Dr. Kristin Sznajder has joined the faculty in the Department of Public Health Sciences to work with Dr. Wenke Hwang in fostering the Penn State College of Medicine’s international initiatives. Currently, she is developing a global health curriculum to be offered within the MPH program and in conjunction with the planned MD-MPH joint degree program. She will also assist in building global outreach programs such as international exchanges, practicums, and field experiences. Dr. Sznajder received her PhD in Epidemiology from University of Michigan and MPH in Global Health from Emory University. Prior to Penn State College of Medicine, she was a Field Epidemiologist with the U.S. Army Public Health Command. Our library services and medical students donated textbooks to MountCrest University to help them start a library.
Sharon Daugherty, Circulation; David Brennan, Collection Development/Digital Resources Management Librarian Resources Management; Tina Lengle, Administrative Support Coordinator for Global Health Center; Amy Ladd, Administrative Support Assistant; Mae Risser, Serials and ILL
Penn State Hershey signs an international agreement with new medical school in Ghana! MountCrest University College will be opening its doors to medical students in 2015. MountCrest University College’s medical school will only be the fifth in the Ghana where physician shortages are dramatic, especially in the outlying areas. MountCrest’s new health campus is under construction in the rural Eastern Region. Related news: http://pennstatemedicine.org/2015/02/06/college-of-medicineand-ghanas-mountcrest-university-college-begin-collaborative-relationship/ Ghana Video BRIDGE Initiative: http://pennstatemedicine.org/2015/02/06/ video-conferencing-program-connects-college-of-medicine-students-with-ruralghana/ From left-to-right: Dr. Ben Fredrick, Director of Global Health Center, Mr. Kwaku Ansa-Asare, Founder of MountCrest University, Ghana, Dr. Craig Hillemeier, Dean and CEO of Penn State Milton S. Hershey Medical Center, Dr. Terry Wolpaw, Vice Dean for Education Dr. Samuel Akortey Akor, Dean of the MountCrest Medical School in Ghana See More
Interview with Dr. Samuel Akor, Dean of MountCrest University by Tony Lin and Stephan Leung, Medical Students Class of 2017 Why do you think students should be excited and interested in global health? The more different scenarios you see, the less surprises you will likely run into in your practice. I learned a lot, especially in terms of care aspect and how you go along with patient care. So that has influenced me quite a lot. Also, in global health, you can learn about how the health care system works in different countries. In other parts of the world, there are constraints with resources and there are cultural differences, so learning about other people’s healthcare systems can help you analyze your own practice in your home country. Another aspect is that we are now in a global world. The recent Ebola outbreak showed that disease has no borders. Most of these diseases that have been eliminated or eradicated in the developed world still exist in developing countries. So the potential for reintroduction of disease is high. That’s why it’s good to know as many different diseases as possible. For example, right now we know that smallpox has been eradicated. So if you ever encounter a smallpox patient, you will not be able to recognize it. So
knowing what the prevalent diseases are in developing countries can help you understand what it looks like and detect it early. During 1984-1985, I remember one German doctor who was visiting a Ghana hospital. She was seeing a case of hepatitis who went into liver failure. She said she had done almost everything and she didn’t know what else she could do to help the patient survive. She asked me if she missed anything. After a moment, I told her that she needed to sterilize the gut and give her metronidazole. She did that and the patient survived. So the benefit of global health is to introduce students and doctors to as many different disease cases as possible so you can recognize and treat them promptly. What is your opinion on the Ebola crisis that is happening right now? The problem with Ebola is that the casefatality rate is very high, so there is not much room for development of herd immunity. Because of this, you need to work fast to break the transmission, or else most of the people will die before herd immunity occurs. This is different from other epidemic diseases where herd immunity will rapidly increase
Dr. Samuel Akor, MB, ChB Dean of MountCrest University’s Medical School, Ghana Medical Training: MB, ChB from Kwame Nkrumah University of Science and Technology, School of Medical Sciences, Kumasi Masters in Community Health at Liverpool School of Tropical Medicine Masters in Health Management, Planning and Policy at Nuffield Institute of Health Studies
Work Experience: Lecturer in community health. Director of the Rural Health Training School Director of District Health Services Director for Policy, Planning, Monitoring and Evaluation, Ministry of Health Head of the Department of Community Health, Kwame Nkrumah University of Science and Technology School of Medical Sciences Executive Secretary of the National Health Insurance Council
if case fatality is low. At a certain level, the transmission breaks and the crisis is averted. The management of the Ebola outbreak is all tied to resource availability from the government and how much they can put in to stop transmission. It is also tied into how people understand the nature of the disease. Ebola transmission is from close contact with sick individuals. It’s difficult for people to understand that they cannot eat with family and stay with other people because this is hardwired into their culture. The other aspect is that in most cases, people first resort to traditional medical practitioners instead of going to a hospital. So these are the challenges we are facing right now in the current Ebola crisis. Can you tell us a little bit more about the MountCrest School of Medicine? Our vision at MountCrest vision is to train the most humane doctors and to train students in a way that encourages lifelong learning. For these reasons, we strived to base our curriculum around the concept of PBL. In the long run, we also aspire to be a leading medical education institution in Ghana and possibly in Africa. We started developing bachelor programs in Nursing, Midwifery, Medical Laboratory,Science, and Physician Assistants. Two years ago I emailed Dean Paz at Penn State College of Medicine and he responded back. Since then, the founder and I have visited PSUCOM four
times in the past year and our reception here has been wonderful. Humanism in Medicine was one key thing that attracted us to PSUCOM because it is our dream to train doctors who care for patients in the most humane way. We have included this element in our program, so we have started discussions on its implementation with PSUCOM. Also in 1991, I was in Canada and got introduced to Problem Based Learning (PBL). So in designing the medical program, one key component that I wanted to incorporate was PBL. Coming to PSUCOM, I not only learned more about PBL but was also introduced to Team Based Learning (TBL). During our visits PSUCOM has been wonderful in assisting our efforts to introduce these elements into our curriculum. Can you describe the current healthcare situation in Ghana and what your medical school will bring to it? We have a multi-tier system from the community level to the national level. So you have Community Health and Planning Services at a community level which is supposed to take care of about 10-12 villages. The Community Health and Planning Services then do referrals to Health Centers which serve the communities at a sub-district level. Then as you go higher, the district level is served by District Hospitals. The curatives and public health services are well integrated at all the levels. This is the basic structure for rural areas.
As you go even higher we have the Regional Hospital where you have doctors for specialties like surgery, ob/ gyn, peds, internal medicine. Beyond that, we have national tertiary hospitals with affiliated medical schools which are for teaching. MountCrest medical school will be affiliated with one of the Regional Hospitals in the Eastern Region and 6 satellite district hospitals . Eventually, MountCrest will have its own teaching Dr. Akor providing tour of land and hospital. construction related to future MountCrest In terms of private hospitals there are two University Health Sciences Campus. kinds – faith-based Christian hospitals
and Islamic hospitals. These institutions are located mainly in rural areas because they are dedicated towards helping the vulnerable population. The private profitable hospitals in Ghana are called self-financing hospitals because they finance their own budget. However, their first motive is delivery of health service, so they prefer to be called self-financing. In 2005, we introduced the National Health Insurance which covers everyone. As of now, the coverage is around 50% but we have a few populations without insurance. We are hoping that we can achieve 80% coverage. What are some challenges that you ran into? The public sector for medical education is almost free so most people will want to apply to those institutions first. If they don’t get accepted to those schools, then look to other alternatives like private institutions. Because MountCrest is a private institution, having enough people that want to apply has been a challenge. But, other than that, it’s the issue of the cost. Most people in the health sector are not able to afford a private medical school education. What happens is that most students want to work full-time while they go to school. Because of this, most of our training is in the evening after the students have finished working. They do not have enough time sit down and learn all about public health and health services management. So the time allocation for the program and the student’s lives seem to be a bit more challenging.
Global Health Night 2015 Over 100 attendees enjoyed conversation, food, posters, and presentations at this year’s Global Health Night, held on January 27th in the University Fitness Center. Organized by the medical student-run Global Health Interest Group, the event brought individuals together from across campus and the local community to learn more about this year’s theme: Vulnerable Populations. Event co-organizer, Elise Mercier (MSII), summarized the evening: Something that struck me during the presentations was the theme of “invisibility” of vulnerable populations. Dr. Zurlo spoke about the alarming number of HIV-infected individuals who remain undiagnosed or untreated. Mr. Wingate told us the story about the homeless community hidden below the underpass, representing a kind of “third world” within our own first world country. Dr. Zaenglein and Dr. Wallace both spoke about the intangible impact that Buruli Ulcer can have on the individual, the family, and the community. In Allison Weinstock’s [Stratton Global Health Scholar] video, she explained that when she first arrived in Senegal, the beauty of the Senegalese culture was hidden, literally and figuratively, by all
of the trash and other signs poverty. Global Health Night, sponsored by the Division of Infectious Diseases, and supported by the Global Health Center and Humanities Department, raised $1000 to be donated to Bethesda Mission and End Buruli Ulcer Alliance.
Global Health Initiative Division of Plastic Surgery
Sebastian M. Brooke, M.D., Donald R. Mackay, M.D. The division of plastic surgery has continued to play an active role in Operation Smile, with Dr. Donald Mackay currently acting as a member of Operation Smile International’s leadership team as Chief Medical Officer. Plastic surgery residents from Penn State have a strong history of receiving the Regan Fellowship to take part on an Operation Smile mission however these international experiences have not been credited as part of their training or toward cases for matriculation. The development of the Operation Smile supported Guwahati Comprehensive Cleft Care Centre in India has provided an opportunity to expand the current paradigm for our residents to recognized training experiences. Permanent staff surgeons at the center, Dr. Gaurav Deshpande and Dr. Hiteswar Sarma, have been appointed adjunct faculty positions for the division of plastic surgery at Penn State. Similar appointments have been made to two supporting international staff intimately involved in the development of the surgical training program at the center, Dr. Alex Campbell and Dr. Carolina Restrepo. Additionally work has been done with the Residency Review Committee for plastic surgery and the American Board of Plastic Surgeons. Our residents now have the opportunity to spend their elective at this world class center as a recognized part of their training. In the last year, two of our residents, Dr. Sebastian Brooke and Dr. Brad Morrow, spent a month each in Guwahati, India. Each resident assisted in the care of between 40 and 50 cleft lip and palate patients. Their surgical experience also included care of orofacial clefts less commonly seen in the United States as well as other congenital deformities. Our current chief residents, Dr. Brett Michelotti and Dr. Sebastian Brooke, have been awarded 2015 Regan Fellowships by Operation Smile to participate on a mission. Dr. Michelotti will be travelling to the center in India with Dr. Mackay in February 2015, and Dr. Brooke will be participating on a mission later in the spring. As greater emphasis is made on the global surgical burden of disease, we recognize the value in credited surgical training and service internationally. Educational experiences such as these are important components in preparing our residents to become leaders on this global stage.
The Dominican Republic Reminded Me of the Reasons Why I Became a Doctor By Dr. Mike Malone, Assistant Professor of Family & Community Medicine It was thirteen years ago since I was a medical student ready to embark on my first international medical journey; a two week Spring Break trip to the Dominican Republic with about twenty of my classmates. It was there in the Dominican Republic that I remembered why I wanted to be a physician. After almost two years of mostly basic science study that left me with only vague memories of why I even wanted to attend medical school in the first place, I was finally able to incorporate the small amount of knowledge I had to make a difference in the life of someone who was ill.
One of the things I remember is how well our team worked together. Here in the United States, we talk about working as a team, but in the DR that is what I truly saw. We had little choice but actually talk to each other on our 30-90 minute commute standing as a group of 20-30 people on the back of cattle trucks while we were driven to the to the location of our clinic that day. I had time to actually learn about the students and other volunteers. Furthermore, attending physicians would discuss difficult cases with each other throughout the day, face to face. Students focused on taking care of patients and not about how they were being evaluated. Everyone was there to learn and help the sick and that automatically engendered an atmosphere of teamwork.
It’s ironic that thirteen years later, I travelled back to the same town and lodging compound in the Dominican Republic and again rediscovered a passion inside me that I had almost forgotten. Although I have been on multiple international trips, every international medical trip has taught me more than I ever anticipated I would learn.
Everytime I visit another country, I am always fascinated about the different culture. In the Dominican Republic, one of the glaring differences was the widespread poverty. Many lived in tin roofed shacks with a lack of routine basic hygiene, medical care, and often shoes. Many of the sugarcane workers suffered chronic effects of their long days in the fields. Many of them were chronically dehydrated, had chronic musculoskeletal conditions, machete injuries, and cataracts from lack of sun protection. Still, despite the lack of wealth, many of the people seemed content. As we drove or walked by
During my time as a medical student, I learned mostly about interesting local medical conditions and treatments. Although, we saw some interesting cases, that really wasn’t what impacted me on this trip.
homes, people waved and smiled as they greeted us. I remember seeing children contently playing with chickens in their yard or enjoying a moment of sweet bliss chewing on a large stick of sugarcane. Life in the Dominican Republic, although hard, seemed free of the hustle and bustle of “American life.” There was something peaceful about the simple life many lived. The patients were very grateful for any care they could receive. We not only treated the patient’s medical conditions, but connected with them on a spiritual level. For just about every patient we saw, we were able to pray for them and their family. Despite waking up early and working long hours with a huge patient load, I was somehow energized by the experience. We may have had limited equipment and medications, but we didn’t have a lot of the baggage medicine in the US carries with it. The trip allowed me to forget EMR frustrations, depart summaries, registries, forms, disability paperwork, malpractice concerns, prior authorization, etc. and focus on the patients. After all, isn’t that what medicine is all about? Hopefully, I don’t need to go back to the Dominican Republic to remember what is most important in life. However, if I ever forget, I know a trip there always seems to help redirect my perspective in the right direction.
For PSU Faculty Traveling Abroad: 1. PSU’s Emergency Number. Please keep this number with you: (814) 863-1111. In cases of emergency or urgency, this phone number will connect you to Penn State. PSU has the resources and infrastructure to be able to provide assistance in cases of emergency/urgency while abroad.
Also, some countries have begun instituting laws related to foreigners providing clinical care. These laws may impose financial penalties and even prosecution as a criminal matter. Please contact our Office of General Counsel to learn more about this important issue.
2. Clinical Care & Medical Malpractice. If intending to provide clinical care abroad you will need to contact Deb Verne dverne@hmc.psu.edu in Risk Management to request that your malpractice insurance be extended to cover you during the time-frame of your travel. Your malpractice insurance does not automatically cover you outside the U.S.
3. HIV PEP. In case of occupational exposure to HIV while abroad, we are providing students and faculty with HIV Post-Exposure Prophylaxis (PEP) kits. These are starter kits with seven days’ of medications. To learn more about these kits and to receive an HIV PEP kit, please contact Tina Lengle tlengle@hmc.psu.edu. Continued on next page
Faculty Traveling Abroad Continued 4. Photos/Videos. Please consider sending Tina Lengle tlengle@hmc.psu.edu photos and short videos while abroad or upon your return. Working with Marketing and Communications Services, we would love to post photos and short (max 15 second) videos to the LionsEye. This can be a great way to highlight global health activities in which our faculty are involved. 5. Online information for faculty. We have included a series of potentially useful links below. Also, please take a look at this online document for more information: http://issuu.com/benfredrick/docs/global_health_faculty_ resources_han Penn State Related Policies: · Graduate Student Policy for Travel to Countries with Warning · Medical missions/humanitarian endeavors (HR70) - Internal only · PSU Policy regarding travel to “Dangerous Countries” · PTO donation program for Medical Missions/Humanitarian Endeavors (HR14) - Internal only
Global Health Scholars Class of 2015 Erin Baneashefski Angela Li Catherine Nicka Jennifer Rice Hannah Wakefield Chelsey Straight Class of 2016 Colin Andrews Kate Belser Daniel Brill Heather Clark Amy Du Michael Freiberg Cameron Hand Timothy Irwin Corinne Landis Nelson Onyango Rajasree Roy Elizabeth Wallace Kodjo Karikari Class of 2017 Andrew Rogers Annie Huyler Mona Lotfipour Henry Montilla-Guedez Hong Loan Nguyen Clay Cooper Jessica Rosenberg
Ida Solis Jonathan Salter Kelsie Herring Kristin Berger Evan Foley Elise Mercier Allison Weinstock Jillian Mitchell Mena Abdelmalak Bilaal Ahmed Mark Nakhla Class of 2018 Celeste Bailey Connor Carmichael Darya Nesterova Elizabeth Thayer Emma Dahmus Eustina Kwon Ivana Marji Jane Trinkkeller Jordan Trubiano Julie Marsala Kyla Halsor Laura Leuenberger Leah Sitler Lindsay Bacik Nathan Bicher Nicole Hammond Olivia Munizza Otto Schoeck Rebeca Martin Rolfy Perez Holguin Temitope Adebayo Wilbert Beachy Zachary Hutchinson
The Global Health Center provides organization and oversight for the medical center’s educational, service, and community research activities in global health. The Center is responsible for promoting global health issues on campus. If you would like to contribute to the quarterly newsletter, or if you are not receiving this publication, but would like to be added to the list, please send an email to nfredrick@psu.edu. Director of Penn State College of Medicine’s Global Health Center: N. Benjamin Fredrick, MD, Family and Community Medicine Global Health Center Advisory Board: Dennis Gingrich, MD (Family and Community Medicine) Brandt Groh, M.D. (Pediatrics) Graham Jeffries, M.D. (Medicine) Daniel Wolpaw, M.D. (Humanities) Jose Stoute, M.D. (Infectious Disease) Jim Holliman, M.D. (Emergency Medicine) Alawia Sulliman, M.D. (Pediatrics) On the Web: http://www.pennstatehershey.org/web/globalhealth Like us on Facebook: http://www.facebook.com/PSUGlobalHealth If you would like to receive Global Health Center announcements, please notify Tina Lengle:tlengle@hmc.psu.edu.
If you are interested in donating to the Global Health Center Scholarships fund you can: 1. Send a check to the Penn State University Global Health Center 2. Go to the Give Penn State fund on the web at psu.edu 3. Contact Devon Johnson to set up your own scholarship at ddominickjohnson@hmc.psu.edu
giveto.