Feinberg’s 2012 Global Health Day Presenter Abstracts
Co-sponsored by FSM’s Center for Global Health, FSM’s Student Committee for Global Health, & the Global Health Initiative at Chicago Lake Shore Medical Associates
September 5, 2012 Dear guests, students, faculty, and administrators, Good evening. We would like to offer a warm welcome to each of you and thank all of our guests for attending Feinberg’s 2012 Global Health Day to learn more about the diverse global health projects and programs in which Feinberg students and McGaw residents have participated over the last year. The Center for Global Health offers its sincere congratulations to all of the presenters tonight, who have worked diligently to prepare for this event. They have each made a significant decision to incorporate global health into their medical education and careers in a meaningful way and this event is an opportunity to share their global health projects with the Northwestern community. The motivation for Feinberg’s Global Health Day in part comes from the unprecedented interconnectedness of our times, which is rapidly transforming our institutions and communities as well as our health care systems. Prior beliefs and ideas about international health and global disease burdens are changing rapidly and the field of global health is growing partly due to high interest from medical trainees, clinicians, and researchers, but primarily due to pressing public health issues, including questions relating to health equity and access to care, which are creating urgent dilemmas in resource-limited and high-income communities around the world. Many of the posters you will see tonight grapple with these difficult issues. FSM’s Center for Global Health is very pleased to co-sponsor this event with the Global Health Initiative at Chicago Lake Shore Medical Associates, who we thank for their generous support. Also, FSM’s Student Committee on Global Health has played an integral role in planning the event and by encouraging their peers to present and attend. I would like to extend particular thanks to student committee members Annsa Huang, Elaine Coldren, Cristina Thomas, and Phoebe Arbogast for their contributions. The Center is proud that this is a student-sponsored and supported initiative. Please enjoy the poster session and continue reading to learn more about projects from FSM & McGaw presenters. Sincerely,
Robert L. Murphy, MD, Director, FSM Center for Global Health Daniel Young, MPA, Associate Director, Global Health Education
Institution / Location
Abstract 1. Social Determinants of Health: An Introductory Curriculum in a Global Context
Ruben Frescas, Jr., MD, MPH
Medical School of the Aristide Foundation University, Haiti
Lopa Basu, DO, MPH, MBA
Abstract 2. Global Health and Simulation: Resident Implementation of a Low-Resource Simulation Curriculum at Bugando Medical Center in Mwanza, Tanzania
Brittany Allen, MD; Marin Arnolds, MD; Nima Desai, MD; Zarina Dohadwala, MD; Alanna D Higgins, MD, MPH; Kyle Jackson, MD, MPH; Mary Prahl, MD; Molly Shane, MD; Michelle Williams, MD; Michael Pitt, MD
Bugando Medical Center, Tanzania
Abstract 3. The Conceptualization of Intimate Partner Violence in Northern India
Fulbright-Nehru Student Research Fellowship, India
Abstract 4. The Evolution of the HIV/AIDS Epidemic in South Africa
Stellenbosch University, South Africa
Abstract 5. Tetanus: Neither Gone Nor Forgotten
Phoebe Arbogast Chris Deyholos
UniversitĂŠ de Cheikh Anta Diop, Senegal
Anne Reihman Abstract 6. Assessing and Addressing Health Care Needs in Rural Uganda
Thomas Carberry Chelsea Williams
firstname.lastname@example.org email@example.com firstname.lastname@example.org
Makerere University, Uganda
Thomas-Carberry@fsm.northwestern.edu email@example.com Quentin-Youmans@fsm.northwestern.edu
Institution / Location
Kate Farner Abstract 7. The Casualty Ward
Daisy Hassani Minjy Kang
Stellenbosch University, South Africa
firstname.lastname@example.org email@example.com Paul-Trinquero@fsm.northwestern.edu
Paul Trinquero Abstract 8. Disability and HealthRelated Quality of Life in Lymphatic Filariasis Patients
Institute of Applied Dermatology, India
Abstract 9. Comparison of Beliefs and Stigma Associated with Chagas Disease amongst Bolivian Highlanders and Lowlanders
Centro Medico Humberto Parra, Bolivia
Abstract 10. My Experience at Centro Medico Humberto Parra: A Focus on Diabetes Education
Centro Medico Humberto Parra, Bolivia
Abstract 11. The Reality of Rural Health under a Universal Healthcare System
Child Family Health International, Ecuador
Abstract 12. Maternal Health in Oaxaca, Mexico: The Role of the Midwife in Rural Medicine
Elaine Coldren Teresa Gomez Amy Lu
Northwestern University Alliance for International Development & Child Family Health International, Mexico
Manuel-Bramble@fsm.northwestern.edu Teresa-Gomez@fsm.northwestern.edu Yiyang-Lu@fsm.northwestern.edu
Institution / Location
Abstract 13. Practice of Traditional Chinese Medicine at a Modern Hospital in Beijing
Peking University, People's Republic of China
Abstract 14. A Lesson Learned from the Infectious Disease Department at L’hopital Avicenne: the Necessity of Raising Public Awareness for Communicable Diseases
Avicenne Hospital, France
Abstract 15. Hadassah University Hospital and the Israeli Health Care System
Hadassah University Hospital, Israel
Abstract 16. Abandoned Babies’ Stories as a Reflection of the Social and Public Health Problems Facing Albania
Angel’s Cradle Program, Albania
Abstract 17. Learning Medicine in Mexico: More than an Education
Hillside Health Care International, Belize
Abstract 18. Development of International Health Opportunities for Northwestern University Department of Physical Therapy and Human Movement Sciences
Abstract 19. Rural Healthcare Delivery through the SE Alaska Regional Health Consortium
Cristina Bolstad, Denise Gates, Jill Lewandowski, Jeffrey Martini, Colleen McGraw, Erin Murray Nora J Francis, PT, DHS, OTR
Toni Sander, PT, DPT, MS
South-East Alaska Regional Health Consortium (SEARHC) 4
Institution / Location
Abstract 20. Treating Tuberculosis in Dakar: A Discussion of Tuberculosis Treatment Standards and the Barriers Opposing Effective Care in Senegal
UniversitĂŠ de Cheikh Anta Diop, Senegal
Abstract 21. Health Care Providers' Response to Sexual Violence Survivors: Exploring Local Strategy Compared to International Guidelines
Makerere University, Uganda
Nigerian Institute of Medical Research
Abstract 23. Clinical shadowing in Uganda: Shedding Light on Some Barriers to Better Health Outcomes
Makerere University, Uganda
Abstract 24. An Ethical Model of International Service and Resident Surgical Training in an OB/GYN Residency Program: A Clinical Rotation in Borongan, Eastern Samar, Philippines
Elizabeth W. Patton, MD
Eastern Samar Provincial Hospital, Philippines
Abstract 22. HIV Outpatient Clinic in Lagos, Nigeria with Emphasis on Prevention of Mother to Child Transmission
Abstract 1. Social Determinants of Health: An Introductory Curriculum in a Global Context Ruben Frescas, Jr., MD, MPH & Lopa Basu, DO, MPH, MBA In humanitarian work much focus is given to disaster relief, but the environmental and social problems that breed illness and disease remain present. Many solutions lie within those affected, but the lack of representation is evident. To participate, local advocates need familiarity with the language, resources, systems, and approaches to engage with foreign aid/ relief providers. Students in medical training abroad are uniquely situated to gain leverage as public health advocates. Through a well-supported curriculum, these students will lead as advocates for their own patient populations. The curriculum focuses on basic public health, epidemiology, data gathering/interpretation, advocacy strategy and intervention planning, as well as intervention evaluation. The advent of this introductory curriculum allows students to incorporate key skills to help self-advocate for their patient's and vulnerable populations. A case study of this proposed curriculum conducted in Haiti (March 2012) shows a practical example of this model. The course was carried out through the organization, Physicians for Haiti originating at Harvard. The organization is connected with the University of Dr. Aristide Medical School and invites visiting professors to lecture at the newly re-opened university. Having opened after the return of former Haitian President Aristide, and following the earthquake damage, the school is slowly returning to normal operations. We were the first visiting professors to the program invited to lecture on Social Determinants of Health. The curricular format was independently devised to meet the 2-week time frame of our visit to lecture to 126 Haitian medical students. The course goal was to "understand and use the social determinants of health to advocate for Haitian patients and communities, especially the disenfranchised, in improving their quality of life and well being with accountability". The course has three main objectives: 1) Understand the definition of the social determinants of health and its importance, 2) Able to identify a problem statement for a given issue, and identify the relevance of history, stakeholders, indicators, communication techniques and evaluating proposed interventions, and 3) Working in groups and presentation preparation. Using materials from the World Health Organization as a basis to formulate the course, we were able to pilot on March 2012. The course concluded with student presentations, where a group presenting on "High prevalence of deforestation in Haiti since 2000" presented a unique perspective and winning an award of recognition for their work. Continuing relations with the Aristides will help to facilitate a longer course for the medical school. The studentsâ€™ enthusiasm and positive response of the curriculum has led to expansion of the curriculum as a longitudinal component. The authors continue to explore and work with the medical school to instill the continuation of the curriculum.
Abstract 2. Global Health and Simulation: Resident Implementation of a LowResource Simulation Curriculum at Bugando Medical Center in Mwanza, Tanzania Brittany Allen, MD; Marin Arnolds, MD; Nima Desai, MD; Zarina Dohadwala, MD; Alanna D Higgins, MD, MPH; Kyle Jackson, MD, MPH; Mary Prahl, MD; Molly Shane, MD; Michelle Williams, MD; Michael Pitt, MD Background: Since 2007, residents at Ann & Robert H. Lurie Children’s Hospital of Chicago have had the opportunity to travel to Bugando Medical Center (BMC) in Mwanza, Tanzania, as part of an international health elective during their third year of training. Bugando is an 850-bed tertiary referral hospital located in the northwest of Tanzania on Lake Victoria. The hospital serves a population of roughly 13 million people. The Medical Center also houses a health sciences college, which functions to educate some 800 students in various medical realms. This is critically important as Tanzania has the lowest ratio of physicians to patients in any country in the world, with only one physician to every 30,000 patients. Motivation: In 2008, a collaborative medical exchange was established with BMC when a group of Tanzanian residents first traveled to Chicago for a month-long medical experience at Lurie Children’s. A needs assessment revealed that the Bugando residents found participation in simulation exercises at Lurie Children’s to be useful and that they wished to have a similar training option at Bugando. In response to this, participating Lurie Children’s residents are now trained to facilitate these simulation exercises in a low resource environment. Implementation: Throughout the year, Lurie Children’s residents travel to Mwanza in small groups to spend four weeks on the pediatric wards. Lurie residents carry out the simulation curriculum with Bugando residents, interns, medical students, and assistant medical officers. At Bugando, simulation is carried out solely with the aid of an inflatable mannequin and scenarios based on BMC’s own management guidelines. Cases are chosen and tailored to the motivations and needs of the learners at Bugando. Topics include emergency scenarios such as cerebral malaria, gastroenteritis, diabetic ketoacidosis, and respiratory arrest. Sessions are approximately 1015 minutes in length with an additional 10-15 minutes for debriefing. Discussions center on medical management but also stress teamwork, leadership and communication skills. Cases contain specific learning objectives that are reinforced during the debriefing. Conclusion: The implementation of low-resource pediatric medical simulation training in Tanzania is a low-cost, high-yield exercise that enhances participants’ medical knowledge and communication skills. In addition, simulation provides Lurie Children’s residents with a well-defined educational role during their rotation in Tanzania. Moving forward: Assessments of experiences of participants from both countries are ongoing. Our hope is that more feedback on how to further develop the curriculum will strengthen Lurie Children’s resident contributions to medical education. Our goal is to sustain a mutually beneficial relationship with medical staff and trainees at Bugando Medical Center.
Abstract 3. The Conceptualization of Physical Intimate Partner Violence in Northern India Maya Ragavan; Kirti Iyengar, MD; Rebecca Wurtz, MD Background: Intimate partner violence (IPV) is recognized worldwide as a serious medical and public health concern for women. Past research has shown that the percentage of women affected by physical IPV in India ranges from 5.3% to 56% depending on the state. Additionally, there are a number of socio-demographic predictive and protective factors associated with physical spousal abuse such as educational level and socioeconomic status. However, few studies have focused on understanding Indian men and womenâ€™s attitudes about physical IPV. This qualitative study in Udaipur, Rajasthan aimed to understand the context surrounding physical abuse as well as options available for victims of physical abuse. Methodology: This study was conducted in Udaipur, India and consisted of semi-structured interviews of 56 women, 52 men, and 12 experts in the field of IPV prevention (n=120). Participants were recruited using purposive convenience sampling with the aide of the non-governmental organization (NGO) Action Research and Training for Health (ARTH). The interview guide was designed as a collaborative effort by the authors, refined during pilot testing, and changed throughout the data collection process due to the iterative nature of qualitative research. Interviews were conducted in either Hindi or Mewari (the local dialect) with the help of an interpreter. The data was analyzed using standard qualitative methodologies. Audio recordings from the interviews were transcribed, coded using the Atlas.ti software package, and then analyzed for recurrent themes using a grounded theory approach. Results: Wife beating was found to be neither fully socially accepted nor socially prohibited. A husband hitting his wife was justified for various reasons including the wife having an affair, disrespecting the husband, or not doing housework. However, the concept of samjhana or making the wife understand was stressed as an important action for the husband to take before he could hit. Socially prohibited forms of wife abuse occurred when a husband hit his wife without a reason, especially if the man was intoxicated. Clear patterns also emerged indicating the perception that a woman will tolerate physical abuse to preserve her reputation and protect her childrenâ€™s futures. For this reason, it was considered inappropriate for abused women to reach out to the police for help or to seek a divorce. On the other hand, culturally accepted forms of separation such as nata (a wife leaving her husband to live with another man) were more socially condoned. Discussion: Through in-depth interviews, we gained an understanding of the intricacies surrounding the social prohibition or tolerance of physical spousal abuse. It is clear from this study that physical abuse without a reason was not accepted among participants but that a lack of options and the importance placed on maintenance of the home made it difficult for a wife to leave an abusive situation. Interventions focusing on promoting widespread awareness of spousal abuse as well as setting up easily accessible intimate partner violence support centers should be attempted. Using the results of this study, we are currently designing a pictorial-based booklet to spread awareness about intimate partner violence and also provide women and men the opportunity to discuss their perspectives about these topics.
Abstract 4. The Evolution of the HIV/AIDS Epidemic in South Africa Monica Boen South Africa has the largest population of people in the world with HIV/AIDS—with a total of 5.6 million people living with this devastating disease. The story behind why HIV/AIDS exploded in South Africa is rooted in South Africa’s socioeconomic history. Before the big wave of HIV/AIDS hit in the 1990s, South Africa was plagued by migrant labor facilitating concurrent sexual relationships, economic inequality, unequal access to healthcare, and racial segregation. These were some of the factors responsible for the evolution of the HIV/AIDS epidemic in South Africa. In the late 19th century, the discovery of gold and diamonds in South Africa increased the demand for laborers. Young black rural South African men supplied this demand, and left their families for long periods of time to work in the mining industry, which created the migrant labor system. Men found alternative sexual partners when they were away from their wives, leading to widespread prostitution. The migrant labor system produced fertile grounds for the spread of sexually transmitted diseases, such as HIV. Apartheid, a form of legalized racial segregation in the 20th century, enforced the migrant labor system and was responsible for economic and healthcare inequalities for South African blacks. The Apartheid government caused the relocation of black South Africans from white farms into “black spots,” which created townships, or shack settlements. These townships had massive overcrowding, and many residents had sexually transmitted infections and tuberculosis, which are associated with the rapid spread of HIV because these diseases compromise immunity. Unequal access to healthcare and poor living conditions left the South Africans vulnerable to an HIV epidemic. I was able to observe and participate in the healthcare system in South Africa, including the townships, and saw many of the challenges and successes to curb the HIV/AIDS epidemic. There is still a large demand for HIV related health care for the black South Africans. However, HIV patients are now able obtain free antiretroviral medications, and there are specialized HIV clinics and more community based care. In addition, South Africa has been promoting several prevention campaigns including male circumcision, and peer education to increase safesex practices. South Africa’s socioeconomic history with its migrant labor force, economic and healthcare inequalities, and the unfortunate ramifications of Apartheid all played a role in the HIV/AIDS epidemic. Strategies to prevent the spread of HIV must take these factors into consideration. Hopefully, prevention and care plans will halt the evolution of the HIV/AIDS epidemic in South Africa.
Abstract 5. Tetanus: Neither Gone Nor Forgotten Phoebe Arbogast & Chris Deyholos Tetanus is a serious, life-threatening disease caused by the bacterium Clostridium tetani. Commonly present in dirt, feces or saliva, the bacterium enters the body through superficial wounds and releases neurotoxins that can result in a minor scraped knee escalating into an excruciating hospital stay or even death. The pathogenic toxin, tetanospasmin, acts to inhibit the release of inhibitory neurotransmitters in the CNS, resulting in overstimulation and deregulation of motor and autonomic pathways. As a result, the patient experiences tonic muscular contractions, dysphagia, and painful paroxysms. While tetanus infections have been largely eradicated in Western nations as a result of aggressive and widespread immunization programs, they remain a significant public health concern in many developing nations. Infant mortality rate, an important measure of a countryâ€™s health, is considerably impacted by the prevalence of neonatal tetanus in the developing world. In total, approximately 1 million cases of tetanus are reported worldwide annually, with an estimated 300,000-500,000 deaths per year. Senegal is one such country where tetanus is far from rare. Over the course of a two-month rotation in the Infectious Disease department at Fann Hospital in Dakar, more than a dozen individuals suffering from tetanus infections passed through the intensive care unit. However brief, this clinical experience illuminated the importance of having a concrete understanding of tetanus in a global health context. In this study, we will present an overview of tetanus specifically as it pertains to resource-limited settings. We will focus on the clinically important presentation, diagnosis, and treatment. While medical students in America may come across tetanus on their Board exams, they are unlikely to ever encounter a case in clinical practice. Still, the presence of this infectious disease in clinics and hospitals in developing countries should not go ignored. Tetanus continues to have a significant effect on the health of many nations and as such, it is imperative that those involved in global health have a familiarity with the disease.
Abstract 6: Assessing and Addressing Health Care Needs in Rural Uganda Thomas Carberry, Anne Reihman, Chelsea Williams, Quentin Youmans Introduction: Uganda suffers a high rate of morbidity and mortality. The country has an average life expectancy of 52 years (global average = 68 years) and a children under five mortality rate of 99 per 1000 births (global average = 57 per 1000 births) (WHO 2012). Ugandans living in rural villages tend to be disproportionately affected by disease due to lower socioeconomic status and limited access to health resources (Kiwanuka et al 2008). Health interventions in rural areas are needed to eliminate health inequality within Uganda. Project objectives: An evaluation of the rural village of Kaduka, Kumi District was performed in June of 2012. The goals of this evaluation were to determine the greatest health care need and develop an effective intervention to address this concern. Methods: One hundred of approximately three hundred families in Kaduka were surveyed. Each family completed a community assessment questionnaire that examined demographics, water supply, sanitation, use of malaria nets, teen pregnancy, malnutrition, diarrhea, and transportation of the family. Based on results of the questionnaire and community input, a plan to address one of the health care needs identified was developed and implemented. Questionnaire results: Malaria, diarrhea, water cleanliness, and sanitation were found to be four of the largest health concerns for families in Kaduka. Of the families surveyed, 72.7% reported at least one case of malaria in their family over the previous six months. There was a significant difference (p=.018) between the mean ages of kids in families reporting an episode of malaria versus families that did not, with malaria-affected families having more children younger than five years of age. Only 48.5% of all families reported having at least one mosquito net. The most common sources of drinking water were the lake (30.3%), a borehole (44.4%), or both (24.2%). Only 10.2% of families reported treating their water before drinking it. Prevalence of diarrhea among families surveyed was 69.7%. Pit latrines were the most common means of sanitation in the community, with 51% reporting they had a working pit latrine. All but two of these families said they shared the pit latrine with one or more other families. The average number of people using one pit latrine was 33. Intervention: A meeting was held in Kaduka to provide the results of the questionnaire and to educate the villagers on pertinent health related behaviors (i.e. water treatment, use of mosquito nets, etc.). Additionally, 100 insecticide-treated mosquito nets were bought and distributed to 68 families with one or more children less than 5 years of age. Conclusion: The rural village of Kaduka has a high prevalence of malaria but a low usage of malaria preventive measures like mosquito nets. One hundred insecticide-treated mosquito nets were bought and distributed to sixty-eight families with children less than five years of age in an attempt to reduce the incidence of malaria within the community.
Abstract 7. The Casualty Ward Kate Farner, Daisy Hassani, Minjy Kang, Paul Trinquero While the term “casualty ward” is typically synonymous with “emergency department,” casualty at the Stellenbosch Provincial Hospital treated a range of health concerns much broader than the acute problems most emergency departments face. During our summer shadowing at this hospital, many of the health issues unique to South Africa were reflected in what we observed in casualty. Stellenbosch Provincial Hospital is a public primary care hospital providing free care to those in Stellenbosch and its neighboring townships. Smaller primary care day-clinics located in the townships refer patients to Stellenbosch. Patients at Stellenbosch can then be referred to the secondary and tertiary hospitals at Paarl and Tygerberg. The disease burden in South Africa is characterized by the consequences of violence (interpersonal violence injury accounts for 6.5% of total DALYs), HIV (17% adult prevalence), TB (prevalence: 795 per 100,000 population), and chronic diseases such as cardiovascular disease and diabetes (prevalence: ~320 per 100,000 population). Due to these factors, as well as a shortage of physicians and resources, primary care hospitals like Stellenbosch must serve as a filter to efficiently allocate the limited secondary and tertiary care resources. With only 8 physicians staffing the hospital and 9 clinics for a population of 140,000, the casualty ward has to accommodate primary health concerns in addition to emergency cases. In our experience in casualty, we noted how the unique public health issues of South Africa and the systemic constraints in the delivery of medical care were reflected in the handling of health issues such as orthopedics, chronic disease, and emergency care. Orthopedics provides a particularly good example of how the healthcare system in South Africa is optimized to provide care to as many patients as possible. If a patient came in with a broken arm, doctors in the casualty ward had to decide whether the patient should be referred to a higher-level hospital for surgery or if an acceptable level of care could be reached by a quick, plaster cast. The bulk of the orthopedic cases are handled in casualty, and then evaluated in a weekly casting clinic at Stellenbosch, where patients are rapidly seen in an assembly line-like system. Chronic disease management was another major role of casualty at Stellenbosch hospital. Many of the patients in the casualty waiting room present with severe hypertension or advanced diabetes, often due to the fact they had defaulted on their prescribed medications. While the cost and distribution of these medications are well covered by the health care system, many patients do not understand the importance of taking their medication, and may even have difficulty grasping the concept of calories and carbohydrate content. Emergency care is also managed in casualty, but the physicians at Stellenbosch must balance emergent medical treatment with chronic disease management. They deal with emergency cases as they come in, and conduct primary care patient interviews in the meantime. In a budget-constrained public system like South Africa’s, every dollar spent on one patient is a dollar taken away from someone else. Therefore, it is more efficient to accept a slightly worse outcome while treating a large group of people than to provide optimal care to only a select few. Similarly, more advanced and specialized care must be reserved for those patients who truly require it, hence the referral system of clinics up through tertiary care centers. Stellenbosch hospital, and the health care system as a whole, operates under the philosophy of providing the best care possible to as many patients as possible. The casualty ward is critical to this system, 12
serving as a gateway to allocate the specialized resources of Tygerberg and Paarl to only the highest yield cases. By screening patients in this referral system manner, the limited advanced health care resources are provided to those who truly need it, while others get a basic level of care, allowing for health care coverage to the largest proportion of patients possible.
Abstract 8. Disability and Health-Related Quality of Life in Lymphatic Filariasis Patients Cristina Thomas Background: Lymphatic filariasis (LF), a mosquito-borne parasitic disease, is the second leading cause of life-long disability worldwide and contributes to more than 4.4 million disability-adjusted life years in men and 1.3 million disability-adjusted life years in women. Besides the physical impairment caused by chronic lymphedema, significant psycho-social damage and social stigma is associated with elephantiasis, a symptom that commonly accompanies the disease. Although several studies have evaluated the impact of lymphatic filariasis on patients’ daily lives, the relationship between disability and health-related quality of life (HRQoL) has not yet been explored. The objectives of this study were to first, assess disability in relation to skin-specific and diseasespecific quality of life and to second, determine demographic and disease characteristics that influence disability and HRQoL. Methods: Disability was evaluated with the World Health Organization’s Disability Assessment Schedule (WHODAS 2.0), and HRQoL was measured with the Dermatology Life Quality Index (DLQI) and the Institute of Applied Dermatology’s LF-specific QoL Instrument. In addition to these questionnaires, subjects were asked to complete a demographic and disease questionnaire. Lymphedema was staged based on the International Society of Lymphology’s staging system. Wilcoxon Rank Sum test was used to compare patient scores with those of controls, and Spearman’s correlation test demonstrated correlation between disability and HRQoL. Results: A total of 36 patients with lymphatic filariasis and 36 controls were enrolled in this study. Twenty-one patients had stage II lymphedema, and fifteen patients had stage III lymphedema. A significant difference was noted between the total scores of patients and controls with the WHODAS 2.0 (P<0.001), DLQI (P<0.001), and LF-specific QoL Instrument (P<0.001). However, scores among patients were not significantly affected by the stage of lymphedema. Disability measurements were positively correlated with DLQI ( r = 0.75, P <0.001) and LFspecific QoL Instrument (r = 0.91, P<0.001) scores. In comparing perceived days of disability, LF patients experienced more days of limited activity than controls (P<0.0001). However, there was no significant difference between the number of days of total inactivity due to health conditions for patients and controls. Additional statistical tests are being performed to determine the benefits of each questionnaire in gauging the impact of LF on patient’s daily lives. Conclusions: Based on our findings, grade II and grade III LF patients experience greater disability and lower HRQoL than the general population. In addition, severity of disability but not stage of lymphedema is correlated with HRQoL. Although patients are not totally debilitated by their disease, lymphatic filariasis does limit the activity a patient can perform. In this way, improvements in disability measures may be an important outcome for treatments that aim to provide LF patients with increased quality of life. Because of the unique psychosocial and physical limitations the disease imposes, disability and HRQoL measures are crucial to determining effective treatments and ensuring maximal integration of lymphatic filariasis patients back into society.
Abstract 9. Comparison of Beliefs and Stigma Associated with Chagas Disease amongst Bolivian Highlanders and Lowlanders Karina Nieto Chagas is a Neglected Tropical Disease (NTD) that afflicts nearly 10 million people worldwide. It is a parasitic disease caused by Trypanasoma cruzi that is mostly transmitted via insects referred to as vinchucas by Bolivians. When transmitted to man, it enters the bloodstream and lodges in the muscle and heart tissue, affects the digestive system, and may be transmitted from mother to fetus during pregnancy. The patients affected may be asymptomatic or present with cardiomyopathy, hepatomegaly, splenomegaly, enlarged lymph nodes, arrhythmia, or tachycardia. Vinchucas inhabit the roofs made of motacu (a type of palm tree) that are commonly found on adobe houses, consequently affecting the rural poor disproportionately. The Centro Medico Humberto Parra Clinic in Palacios, Bolivia, serves a rural patient population afflicted by Chagas. Patients primarily belong to two ethnic groups, Highlanders and Lowlanders, who Bolivians refer to as “Collas” and “Cambas” respectively. During colonization the Spaniards and the Indigenous Lowlanders gave rise to the Mestizos, whereas the Highlanders remained segregated geographically by the Andean Mountains, and economically. Since the 1970s, when waves of migration of Highlanders to the lowlands began due to the cultivation of cotton, there is now a larger presence of the two ethnic groups who have maintained autonomous identities, values, and cultures. The primary objective of this research project was to gain a better understanding of Highlanders’ and Lowlanders’ background, cultural attitudes, stigmas and beliefs towards Chagas. Chagas-positive and Chagasnegative patients were interviewed. Patients who stated they were Chagas positive were considered to be Chagas-positive. Patients who were unaware of their Chagas status or who stated they were Chagas negative, were considered to be Chagas-negative. To capture the degree of stigmatization, Chagas-positive patients were provided with additional questions. During a four-week study, 99 patients were interviewed: 60 Lowlanders, 37 Highlanders, and 2 belonging to another ethnic group. Overall, 25% of the patients were Chagas positive; 27% of Lowlanders and 22% of Highlanders were afflicted. Chagas-positive patients’ overall level of stigmatization was calculated using a point system. Fifty-seven percent of Highlanders and 69% of Lowlanders had low stigmatization levels of “never or rarely.” However, 14% of Highlanders were calculated to have stigmatization levels of “frequently,” in contrast to 0% of Lowlanders. The majority of patients belonging to either group understood that Chagas is a disease that is related to the vinchuca, but they had a poor understanding of the lifecycle of the parasitic disease; only 1 of the 99 patients interviewed knew that Chagas is caused by a parasite. The majority of patients also indicated that the disease was not transferrable from one person to another. Although the disease is not contagious, it is transferrable by blood, a point that is especially important for women of childbearing age to be aware of since a newborn who is Chagas-positive is treatable. There was not a statistically significant difference in the following demographic categories between the two ethnic groups: age, age of Chagas-positive patients, number of children, and number of patients living with a partner. 15
A striking difference between the Highlanders and Lowlanders was the time needed to reach the clinic from their homes. The time needed for Highlanders to reach clinic is substantially longer than Lowlandersâ€™, with a 2.10 hour one-way trip in comparison to the Lowlandersâ€™ 1.50 hour one-way trip (p = 0.004). An additional significant difference was the level of education achieved: 76% of Highlanders and 45% of Lowlanders had completed elementary school or less (p = 0.003). Given this data, it is important to consider additional strategies to increase Highlandersâ€™ healthcare access, and to provide appropriate materials using language that corresponds to the patient base. This study shows that there is significant room for improvement regarding patient education, and healthcare access. Lessons on the lifecycle of Trypanasoma cruzi, prevention, and awareness of potential cultural and linguistic barriers are crucial to reduce the incidence of Chagas amongst the next generation of Bolivian Highlanders and Lowlanders.
Abstract 10. My Experience at Centro Medico Humberto Parra: A Focus on Diabetes Education Dayana Bermudez Centro Medico Humberto Parra (CMHP) is a clinic that provides free medical services to several impoverished communities surrounding Palacios, a very small town located 70 miles from Boliviaâ€™s largest city. CMHP is the main source of healthcare for the majority of its patients offering them with primary care, dentistry, medications, and health education. The patient population is diverse, including the indigenous groups Quechua and Aymara. There is a high prevalence of diabetes, playing a large physical and emotional burden on the patients. Even more concerning was the rampant numbers of uncontrolled diabetics who had very little knowledge about their disease. I, along with two other medical student volunteers, began to conduct 30 minute one-on-one health education consults with diabetic patients. The objective was to evaluate patientsâ€™ knowledge as well as create realistic and tangible goals that will improve their health. It became apparent that patients have a very limited understanding of the biology of their disease and how it relates to symptoms, complications, and treatment. Although most patients recognize that healthy eating habits and losing weight are important in controlling diabetes, the vast majority has difficulty following long-lasting behavioral changes. In order to address this gap in knowledge, a number of friendly and easy to understand handouts in Spanish were developed and customized for CMHP patient population. These handouts include one on general diabetes information, which explains the pathophysiology behind the disease, risk factors, and complications. A second handout focused on the different medications and effective insulin injection technique. Lastly, a nutrition handout, which imitates the healthy plate model, was created. Furthermore, I created scripts that systemize the process and help future health promoters with limited Spanish skills continue with this project. The main goal is that the education program will become a permanent and consistent component of patient care and that all diabetic patients have a consult at least once. Thus, a referral form was created which the physicians should use to communicate with the educators and to be documented in patients' charts. To assure the continuity of the program, I led a talk for the health promoters who are already involved in diabetes care and education within the local communities of CMHP. The promoters were very receptive to the handouts and scripts. In conclusion my rotation at CMHP allowed me to gain a new perspective on the impact of diabetes in a resource-limited population beyond what is possible in the U.S. as well as provide better care for CMHP patients by implementing a sustainable education system.
Abstract 11. The Reality of Rural Healthcare under a Universal Healthcare System Kristen Unti Universal care does not mean equal care for all. Despite the provision of universal healthcare in the Ecuadorian constitution that Correaâ€™s administration passed in 2008, many disparities remain between the quality of care that urban populations receive and the care that is provided to the people in rural areas. For example, access to basic care is available to all people, but if one has a complicated illness or emergency in rural areas, it is nearly impossible to get to a hospital that can take care of the problem. Furthermore, it is estimated that only 52% of the population has regular access to careâ€”leaving much of the countryâ€™s population receiving sporadic care at best. The purpose of this work is to address many of the issues regarding the current realities of rural healthcare in Ecuador. What are the geographical, financial, and cultural barriers that prevent indigenous people in Ecuador from receiving health care? How do you ensure that people have access to health services in places that are not even accessible by car or boat? How is the care received by indigenous people who have their own health beliefs that may not align with Westernized health beliefs? Can you successfully mix traditional health practices with more modernized forms of health care to attain better health outcomes? And finally, is the health care that these people are receiving sustainable? The investigations of these questions occurred during a month-long trip to Ecuador as a participant in the Amazon Community and Indigenous Health Program run by Child Family Health International. I participated in service-learning programs in which I was helping to provide care to the Kichwa and Shuar indigenous populations around the town of Puyo while also gaining knowledge about their various cultures and public health issues that exist. The observations that were made during my month-long immersion in rural Ecuadorian healthcare exposed many of the issues that prevent people from accessing appropriate care. More importantly, these observations also led to implications that should be kept in mind whenever one is constructing health policies or campaigns. By analyzing the factors that prevent the rest of the Ecuadorian population from accessing healthcare, suggestions can arise as to how to improve access to healthcare not only in Ecuador, but also in many rural locations around the world.
Abstract 12. Maternal Health in Oaxaca, Mexico: The Role of the Midwife in Rural Medicine Zachary Bay, Manuel Bramble, Elaine Coldren, Teresa Gomez, Krutika Lakhoo, Amy Lu, & Praneet Korrapati The Northwestern University Alliance for International Development (NU-AID) organized a month-long global health program this summer for seven Feinberg School of Medicine students to Puerto Escondido, Oaxaca. NUAID is a student-run organization dedicated to improving international health through community health projects abroad. One of the most alarming statistics about Oaxaca concerns its maternal death rate, which is significantly higher than the maternal death rate for Mexico. In 1991, Oaxaca had a maternal death rate four times higher than most other states in Mexico, and it continues to be one of three states with the highest maternal death rates in Mexico (Merrill & Miró, 1996). Due to the mostly rural landscape and cultural history in Oaxaca, many women enlist a partera (midwife) to supervise their birth instead of going to a local clinic or hospital. Because of the high maternal death rate and frequent use of parteras in Oaxaca, the NU-AID group chose to focus on midwife education for their community health project. In July of 2011, NU-AID sent a different group of Feinberg School of Medicine students to Puerto Escondido. During that program, the group was able to make contact with local physicians and healthcare employees to lay the foundation for a long-lasting relationship between NU-AID and the Puerto Escondido community. Through these local contacts, we were able to design a month-long rotation that involved work in primary care clinics and a community health project. The community health project consisted of preparing and running a week-long medical workshop for parteras from all over the state of Oaxaca. After gathering information about maternal health, parteras, and the culture surrounding pregnancy and birth in Mexico, the group prepared presentations and demonstrations with the nurse who would supervise the workshop. In preparation for running the week-long workshop, the group met with the supervising nurse to practice presentations and skits. During the group’s last week, approximately forty midwives from the state of Oaxaca arrived in Puerto Escondido for the workshop. The presentations were focused on healthy and high-risk pregnancies, prenatal care, healthy and high-risk births, care of a newborn, postpartum care, maternal nutrition, and family planning. The group chose this focus in an attempt to reinforce the parteras’ knowledge of healthy pregnancies and birthing procedures as well as the important signs that can alert the partera to an emergency. This workshop and future workshops will hopefully contribute to the effort in Oaxaca to improve maternal health statistics.
Abstract 13. Practice of Traditional Chinese Medicine at a Modern Hospital in Beijing Alex Pyden The culture and civilization of China have existed long enough so as to preclude clear documentation of their historical origins, as is the case for Chinese medicine. Whereas the traditional roots of western medical theory from Ancient Greece and Rome were largely discarded overtime with the development of empirical science, Traditional Chinese Medicine (TCM) is largely integrated with the culture and worldview of the Chinese people, and its influence and practice have survived for millennia; it continues to be administered in China today, along with western medicine, in a form not extremely different from its description in ancient texts. During my sixweek rotation from June 4 – July 13 at Peking University People’s Hospital (PUPH) in Beijing, China, I spent two weeks observing TCM practice in an urban hospital setting and its interaction with western medicine. TCM theory is fundamentally different from modern western medicine in that it prioritizes maintenance of health and primary prevention of disease over treatment. Good health requires maintenance of harmony and balance among various forces, phases and fluids that support and restrain one another. Most well known of these are the iconic yīn and yáng, more or less representing the energetic and stagnant poles of nature, respectively. TCM also follows the Chinese theory of the five phases of water, wood, fire, earth and metal. These phases, or elements, stimulate and inhibit each other, and must be kept in a dynamic balance. The functions of the main organs also correspond each to an element and likewise affect each other’s function. The balance among these organs is regulated by the flow of substances such as blood and qì through invisible channels, or meridians. Blockages in these channels can lead to disease, and acupuncture or manipulation at certain points along them can be used to restore balance and flow. Disease can result from either excess or deficiency of some force or substance in relation to another. Imbalances manifest in many different ways, and TCM practitioners have honed over millennia various diagnostic methods to detect them. The four main tenets of TCM diagnosis are visual inspection, listening and olfaction, verbal inquiry, and pulse-taking and palpation. Inspection includes a focus on the color and shape of the tongue; all kinds of imbalances and conditions can be surmised from tongue inspection, though a synthesis of information is required to pinpoint a specific disease. Pulse-taking is another very important aspect of diagnosis; a skilled physician can likewise unearth a wealth of information from the characteristics of and variation between the feelings of a few sites along both radial pulses. Once the specific cause of disease is determined, a physician can treat it by supplementation of deficient forces or substances or by purgation of pathological factors. Besides removal of blockages by acupuncture, this can be accomplished by “cupping” therapy, or by administration of herbs with certain therapeutic properties. Finally, PUPH has developed a novel form of acupuncture, termed “acupotomy,” that has shown great effectiveness.
Abstract 14: A Lesson Learned from the Infectious Disease Department at L’hôpital Avicenne: The Necessity of Raising Public Awareness for Communicable Diseases Elena Fradkov Even in a country like France with nationalized medical insurance, where every legal and illegal resident has the right to treatment, there are still many people who do not receive adequate healthcare. Who comprises the underserved population in France, are these people different from the underserved in the U.S.? Unsurprisingly, many are very similar: poor, homeless, alcoholics and drug addicts, illegal immigrants, or even citizens who speak poor French, etc. They do not seek care for symptoms that most would find alarming, because they are often scared, confused, or unaware of the gravity of their condition. Working in the infectious disease department at l’hôpital Avicenne, Bobigny, Paris, where the majority of the patients can be described by the aforementioned categories was an eye opening experience. In addition to acquiring invaluable medical knowledge from physicians, I also learned a lot from talking to the patients I followed. Many arrived through the emergency department, when they had gotten so sick that someone had to call in an ambulance. They did not realize that their cough was due to tuberculosis, another highly drug resistant bacterium that has invaded the lungs, or opportunistic pneumocystosis due to concurrent HIV infection, etc. All of these diseases are life threatening and highly contagious. My experience has shown that a doctor’s mission is more than diagnosing illnesses, draining abscesses, administering antibiotics, ordering scans and doing other patient-centric procedures, but also, especially in a field such as infectious disease, educating the public. It is very important that physicians work closely with policy makers to raise awareness for easily communicable diseases, such as Tuberculosis (TB) and HIV.
Abstract 15. Hadassah University Hospital and the Israeli Health Care System Stanley Gutiontov The Israeli health care system is one of the best in the world. Health care coverage is universal (everyone must be covered under one of four existing HMOs), Israelis enjoy the fourth highest life-expectancy in the world (78/82 m/f), the physician to population ratio is 3.8/1,000 (one of the highest in the industrialized world), and medical tourism by patients the world over is growing. My time at the Hematology Department of Hadassah University Hospitalâ€”one of the five university medical schools in the country, the sixth largest hospital complex in Israel, and a nominee for the 2005 Nobel Peace Prizeâ€”allowed me to experience this system, both from within and, unexpectedly, as a patient. In many ways, the ground rules for the Israeli health care system are similar to those in the United States: it has a well-trained population of medical professionals, technologically advanced facilities and treatment options, and a population in which 2/3 of the deaths are due to malignant neoplasms, heart disease, cerebrovascular disease, diabetes, and accidents. And yet the system, according to many metrics, is more efficient and successful than the one in the United States. Some potential reasons may be: 1. High technology devices, such as MRI machines and CAT scanners, have a cap placed on them by the Ministry of Health. This, in turn, forces Israeli hospitals to buy fewer machines and use them more heavily, which significantly reduces costs. 2. The IT systems that are in place in Israel are cutting edge, and most providers are already adopting EMRs and electronic health exchanges. 3. There appears to be a culture of reform in the Israeli medical system. Rather than pass overarching and enormously complex reforms once every few decades, Israel appears to incrementally change the system every couple of years (for example, when the NHI law was passed, only 5% of the Israeli population was uninsured at that point, and the change was undertaken during a large influx of physicians from the former Soviet Union, who would be able to accommodate the increased patient load). During this presentation, I will discuss these points as well as my experience completing a rotation at Hadassah University Hospital.
Abstract 16. Abandoned Babies’ Stories as a Reflection of the Social and Public Health Problems Facing Albania Ina Jani This past summer I completed a rotation in obstetrics and gynecology in the Mother Teresa University Center in Tirana, Albania. I spent my mornings in clinic and the afternoons volunteering in the Angel’s Cradle Program, an orphanage for babies who get abandoned by their mother right after birth. The newborns stay there until they are three months old, and are then transferred to the permanent orphanage where they enter the adoption process. During my rotation, I interacted with physicians, residents, patients and family members. I observed pre-natal care, deliveries, C-sections, abortions, and sometimes was on call with my team. My rotation taught me about the Albanian health care system and the kind of care patients who have access to medicine get. My volunteering experience taught me about some public health concerns in Albania. Babies’ stories as a reflection of the social and public health problems facing Albania: Baby L. was a beautiful baby girl with gorgeous eyes whose mother was a 17 year old from a poor and isolated village. When she had suspicions about being pregnant, she did not have access to medical care to have an exam, she did not have access to a pharmacy nearby to buy a $1 pregnancy test, and was afraid to talk to her parents because of the stigma associated with a teenage pregnancy. She eventually did seek help but it was too late to have an abortion. Baby M. was an adorable baby boy who gave all the nurses and volunteers a really hard time to be put to sleep. His mother was a sex slave who had no access to any kind of medical care, and who could not afford contraception or condoms. She was not only at risk for unwanted pregnancies, but also for sexually transmitted diseases. The mother gave birth to the baby on her way to the hospital, in the street. When she arrived to the hospital, she was covered in blood, still bleeding, and the umbilical cord was improperly cut and still hanging from baby M. She stayed in the hospital only a couple of hours, leaving behind an unnamed baby. Reflections: What all these stories have in common is that they were unwanted pregnancies. Patients either did not have access to medical care, did not have the necessary information to make an informed decision or did not know their options. According to the Albanian Ministry of Health, contraceptive use prevalence in Albania is 11% (no information on other forms of birth control). In the United States, 33% of women of reproductive age use oral contraceptives, 84% use some kind of birth control. Access to medical care and family planning remains a serious problem in Albania. The Ministry of Health also acknowledges that health education and promotion are key components in raising awareness about reproductive health. They are working with some international organizations to improve women’s access to care and family planning, and reduce the stigma associated with young single mothers.
Abstract 17. Learning Medicine in Mexico: More than an Education Patrick Bender As a developing country, Mexico faces serious challenges to deliver healthcare to its populace. Many of these challenges relate to both the inadequacies of the public healthcare infrastructure as well as to the general poverty of the citizens. To confront some of these problems, Mexico has invested heavily in healthcare, making it the third largest investor in healthcare in the world in terms of spending as a percentage of GDP. This funding has served to construct a public hospital system that provides free medical care to the poorest citizens. Additionally, there now exists government subsidized insurance programs with respective hospitals to treat those beneficiaries. However, with 18.2% of the population falling below the food based poverty line and 47% falling below the asset based poverty line, the public hospitals are almost completely saturated. This has resulted in the development of a private hospital system that offers higher quality healthcare to those who can pay. This two-tiered healthcare system represents a serious obstacle to decreasing healthcare disparities in a population with an increasing burden of chronic illnesses. In an effort to alleviate pressure on the public healthcare system, Mexico depends on medical students to provide care. To meet these public health needs, medical school clinical training is designed to both educate the students and provide the public healthcare system with a workforce. Indeed, many public hospitals depend on fifth-year medical students in order to operate. Medical school programs in Mexico also require a year of social service during the final year of training. During this year, the students are placed in remote, rural locations to care for the populace. Additionally, the operation of screening clinics, such as the Kidney Early Evaluation Program, is largely dependent on student involvement. Without the service of these students, entire rural populations in Mexico would be without medical care of any kind. During my global health experience, I directly observed the Mexican healthcare system by spending four weeks in a private hospital in Mexico City. As part of this experience, I rotated through both the internal medicine and emergency medicine services. In addition to observing complicated patients with advanced chronic conditions such as diabetes, renal failure, obesity, and hypertension, I was able to see what strategies were being implemented to prevent these diseases. Specifically, I assisted with a rural screening clinic through the Kidney Early Evaluation and Prevention program. Additionally, I worked extensively with fifth-year medical students and developed a better understanding of the medical education process in Mexico and its integral part in the countryâ€™s healthcare delivery system.
Abstract 18. Development of International Health Opportunities for Northwestern University Department of Physical Therapy and Human Movement Sciences Cristina Bolstad, Denise Gates, Jill Lewandowski, Jeffrey Martini, Colleen McGraw, & Erin Murray Faculty Mentors: Antoinette P. Sander, PT, DPT, MS; Nora J Francis, PT, DHS, OTR Purpose: Interest in international health experiences to promote inter-cultural interactions and cultural humility in the training of health care professionals is growing. The aim of this project was to explore models of international clinical education (ICE), international service learning (ISL), and other volunteer experiences (OIVS) for the Doctor of Physical Therapy students at Northwestern University and to develop a proposal for implementation of international experiences. Subjects: A total of 113 physical therapist students completed an online survey, 8 faculty members participated in two faculty focus groups, and 5 faculty and international program representatives discussed their experience, personal contacts, and advice for program development. All subjects were from Northwestern University. Materials/Methods: A literature review guided this exploratory study. The results of the literature review provided a specific sequence of steps that guided the development of international health opportunities for the physical therapy department. Meetings with faculty who had international contacts and representatives from Northwestern University Center for Global Health (CGH) took place over the course of the year. A 21-item needs assessment survey was sent to 210 1st, 2nd, and 3rd year DPTHMS students using an online tool, Survey Monkey.ÂŽ Close-ended responses were tallied and open-ended responses were coded with frequency counts. Two 60-minute faculty focus groups with 5 and 3 faculty members respectively were completed. Discussions were recorded, transcribed, and coded by theme. Results: Potential international partners and on-site coordinators were identified in the meetings with faculty and CGH representatives. Response rate for the student survey was 53.81%. 89% of students indicated interest in an international program and ranked in order of preference: ICE, (65 %), ISL (25%), OIVS (12%). 90% expressed interest regardless of language barrier and 84% were willing to participate even with a language requirement. Students were willing to participate in cultural awareness orientation, preferred to travel with 3-5 classmates, and selected year 2 or year 3 of the curriculum for a 2-4 week experience. Both faculty groups supported the concept of an international opportunity. ISL had the most support with the fewest barriers to implementation. Faculty discussed logistical concerns such as cost, time, and integration into curriculum, as well as balancing teaching, research, and service responsibilities and departmental support for faculty participation. Conclusion: In line with Northwestern Universityâ€™s goals and strategic plan, students and faculty demonstrated a need for international health opportunities. Five international opportunities have been selected for further exploration based on the data collected from all sources and the feasibility of implementation. These include ISL in Belize through Hillside Health, ISL in India through Child and Family Health, ICE in Taiwan through National Taiwan University, ISL in Guatemala through Hearts in Motion, and ICE in Chile.
Clinical Relevance: International health opportunities will enable physical therapy students to develop and grow in cultural competence and sensitivity, which can impact future clinical practice.
Abstract 19. Rural Healthcare Delivery through the SE Alaska Regional Health Consortium Chelsea Carlson The SouthEast Alaska Regional Health Consortium (SEARHC) is a non-profit tribal health consortium that was founded in 1975 under the provisions of the Indian Self Determination and Education Assistance Act to serve the health interests of the TlingĂt, Haida, Tsimshian and other Native people living in remote regions of SE Alaska. I participated in a four-week clinical rotation in rural family medicine with SEARHC at its Mt. Edgecumbe Hospital site in Sitka, Alaska to supplement my experiences in urban family medicine with the Education Centered Medical Home program at Feinberg School of Medicine. SEARHC-Sitka has the greatest range of healthcare services in the consortium and serves as a key point of access for SE Alaskan Natives. There are 18 Native communities that belong to SEARHC, and each of these Native communities has a seat on the SEARHC Board of Directors making decisions about the health priorities and allocation of funds among the tribal network. Many of the tribal communities served by SEARHC remain very isolated and can be reached only by plane or boat, and most of them have populations of fewer than 1,000 people making permanent health facilities in these locations difficult to maintain financially. The health burden in these communities however is high, with chronic disease rates on par with national averages as well as a disproportionate amount of rheumatologic disease, substance abuse and suicide. Taken together this makes extensive collaboration between sites and innovative health programming essential for the health of these communities. Delivering health services in rural Alaska is complex with limited resources, transportation difficulties, and a potential for lack of continuity with limited primary and preventative services within the individual communities. Family Medicine as a specialty in this location works to help patients navigate the tribal health system in order to access high quality care, with an appreciation of their role as liaison and advocate for their rural Native patients. The SEARHC model of rural healthcare delivery in SE Alaska is an educational, inspiring and evolving example of communities united in the struggle for quality healthcare in traditionally underserved areas.
Abstract 20. Treating Tuberculosis in Dakar: A Discussion of Tuberculosis Treatment Standards and the Barriers Opposing Effective Care in Senegal Amanda Jichlinski The infectious disease unit of Fann Hospital in Dakar, Senegal receives new cases of tuberculosis (TB), often with HIV co-infection, daily. Tuberculosis remains an enormous health burden throughout the world with 8.8 million people falling ill and 1.4 million people dying of TB in 2010. However, the burden is greatest in Sub-Saharan Africa where there is the greatest proportion of new cases per population worldwide; in 2010, there were more than 270 cases per 100,000 people in the region. Tuberculosis is especially prevalent among AIDS patients. HIV infected individuals with latent TB are 21 to 34 times more likely to develop active TB infection, and worldwide TB is the leading cause of death among HIV infected individuals. Fann Hospital is located in Dakar, the capital of Senegal. As a large public hospital, it provides some of the cheapest available medical care in the city and has a very poor patient population. The doctors at Fann Hospital reported that TB is the most common opportunistic infection among AIDS patients in Senegal. In 2010 in Senegal, the prevalence of tuberculosis was 542 individuals per 100,000, a rate higher than the African regional average of 332 per 100,000.ii However, Senegal had a lower prevalence of HIV among adults age 15-49 years, 9 per 1000, than the African regional average of 47 per 1000. While health care workers in Senegal have had success in treating and controlling the spread of HIV/AIDS, tuberculosis remains a significant health burden that warrants more attention. The WHO is currently advancing â€œThe Stop TB Strategyâ€? with two goals: to reduce the global burden of TB by halting and beginning to reverse the epidemic by 2015 and to halve the prevalence and death rates of TB by 2015, compared to 1990 levels. To reach the goals, the WHO has proposed, among other measures, to expand and enhance the DOTS (directly observed therapy short course) treatment strategy by improving early case detection, standardizing high-quality treatment with effective drug regimens, and increasing the supervision and support of patients on treatment. During my time at Fann hospital, I worked with patients being treated for HIV-TB co-infection and TB infection. I leaned about the methods for diagnosis and treatment of TB used at Fann and witnessed some of the barriers that doctors face when trying to provide effective care. During the first four weeks of my rotation, there was a shortage of reactant needed to test sputum samples for TB. Diagnosis was based on medical history and chest Xray despite TB not always being visible on x-ray in immunocompromised patients. The cost of TB treatment was also a significant problem for patients; many could not afford six months of medication necessary to meet the international standard of treatment for pulmonary TB. For my presentation, I will discuss and compare the WHO standards for diagnosis and treatment of tuberculosis and TB-HIV coinfection with methods I observed in Fann Hospital. While the doctors do their best to follow international standards for treatment of tuberculosis, the cost of treatment and of diagnostic tests is often a large barrier to providing care. Additionally, patients are not always residents of Dakar; since they come in from more rural parts of the country for care, continuity of care becomes difficult when the patients return home. The goal of this presentation is not to identify shortcomings of Fann hospital but instead to increase understanding of the difficulties faced by doctors practicing medicine in a large public hospital in Dakar. 28
Abstract 21. Ugandan Health Care Providers’ Response to Sexual Violence Survivors: Exploring Local Strategy Compared to International Guidelines Kathryn Fay Background: While international guidelines exist for sexual violence response in health care settings, there is evidence that actual practices vary. In Uganda, information has been collected on the prevalence of sexual violence and the experiences of sexual violence survivors. However, there is little information on health professionals’ behaviors and attitudes regarding sexual assault. Objective: This study gathered information on health professionals’ behaviors and attitudes regarding sexual assault, focusing on the applicability and utility of best practices put forth by the World Health Organization and the United Nations’ Inter-Agency Standing Committee Task Force on Gender and Humanitarian Assistance. Specific study objectives included an assessment of the integration of these guidelines into practice, identification of barriers to guideline integration, and exploration of the changes health providers suggest, if any, to sexual violence response protocol. Participants and Methods: This cross-sectional study involved a self-administered, 84-question survey to any health care professional at Mulago Hospital and Kayunga Hospital in Uganda. The survey included questions about demographic information as well as participants’ attitudes towards sexual violence and the role of health professionals. The rest of the survey transformed the two sets of international guidelines into a series of statements, which participants could agree or disagree with using a Likert scale. Data analysis was performed using SPSS (Statistical Package for the Social Sciences). Results: In total, 75 partially or fully completed surveys were collected. Ninety-two surveys were given out at Mulago Hospital and 45 surveys were returned. Forty-three surveys were given out at Kayunga District Hospital and 30 surveys were returned. Some strengths of the current hospital response include the ability to provide free services in most locally spoken languages. Several of the recommended supplies that are useful across a spectrum of services were consistently available, but specialty supplies were not. Many participants felt strongly that staff did not receive enough support or supervision and that staffing levels were too low. Most staff felt that there was successful collaboration with and support from community partners. But, 18.9% of respondents were unfamiliar with a required police forensics form. Staff were divided on whether there is a clear protocol (48% reported I don’t know, strongly disagree, disagree, or neutral). However, there was consensus on the role of supply-shortages. Of the people who felt that there were barriers to change (47 said there are barriers, 21 indicated there are none, and 7 did not respond), 96.2% of respondents agreed or strongly agreed that barriers to change were mostly based on supplies or structural problems. Conclusions: Ugandan health professionals have been receptive to the WHO and IASC guidelines. The vast majority of participants felt that the guidelines were realistic and culturally appropriate. Furthermore, many of these guidelines have been implemented. Participants identified the highest impact changes as improved human resources, infrastructure, community education, and relationships with community partners. Future use of this data set will include analyses of variance to further elucidate important factors to improved sexual violence response. 29
Abstract 22. Public Health Field Experience: HIV Outpatient Clinic in Lagos, Nigeria with Emphasis on Prevention of Mother to Child Transmission Ijeoma Okwandu & Temitope Orenuga This past summer we spent five weeks in Lagos, Nigeria at the Nigerian Institute of Medical Research. Our motivation to intern at this particular site came from our Nigerian heritage and desire to gain insight into the current status of health care delivery systems in the country. Similar to the United States, the Nigerian healthcare system consists of primary, secondary, and tertiary healthcare centers that can be either public or private hospitals or university teaching hospitals. As a branch of the Federal Ministry of Health, the Nigerian Institute of Medical Research is a public institution whose mission is essentially to conduct and disseminate research that addresses the diseases of public health importance, such as HIV/AIDS, malaria, and tuberculosis. HIV/AIDS is a significant and growing health concern among Nigerian citizens. Data from 2009 indicated that approximately 3.3 million Nigerians were living with HIV/AIDS with a prevalence of 3.6% among individuals between the ages of 15 to 49. Due to funding by the U.S. Presidential Emergency Plan for AIDS Relief (PEPFAR), NIMR is universally known for providing free HIV assessment and treatment to Lagos residents through its Clinical Sciences Division. As visiting students in public health our role was to become immersed at NIMR to gain a better understanding of the framework, organizational structure, challenges, and limitations of the institute. The majority of our time was spent in naturalistic observation of the outpatient clinic of the Clinical Sciences Division. The clinic employed a team based approach which consisted of nurses, physicians, pharmacists, and counselors who came together to address the relevant aspects of HIV patient management and care. While observing interactions between NIMR staff and their patients we noticed what seemed to be major gaps in the patientsâ€™ understanding of their disease, particularly among female patients with regards to methods of mother to child HIV transmission. The Prevention of Mother to Child Transmission (PMTCT) program, a specialized clinic of mothers and children, is one way that NIMR seeks to address this gap. In our desire to gain a clear sense of the level of patient understanding we performed informal qualitative interviews with approval of the Head of the Division. The data showed that the level of understanding was highly variable among the women and that a strong belief in God played a significant role in determining their health behavior. Furthermore the women faced significant challenges in dealing with the cultural stigma and financial hardships associated with the decision to bottle or breast-feed. Overall, we were able to gain a greater understanding of medicine, research, and public health in Nigeria through our experience at NIMR. We observed the undeniable influence of culture on the practice of medicine and healthcare delivery and witnessed how the weak infrastructure of the health care system and poor organizational culture decreases the effectiveness of intervention programs such as PEPFAR.
Abstract 23: Clinical shadowing in Uganda: Shedding Light on Some Barriers to Better Health Outcomes Sonja Skljarevski As a nation in the developing world, Uganda suffers from many health inequalities. Presently, the life expectancy of Ugandans at birth is 52 years, while it is 79 years for Americans. The striking difference between these two numbers becomes more understandable when underlying factors are considered. For example, the physician density per 10,000 population is estimated to be 1.2 in Uganda, while it is 24.2 in the US. Furthermore, since the majority of for-profit and government hospitals are located in urban areas, access is more problematic for Ugandans because only 13% of the population lives in urban areas, as compared to 82% of the US’s population. In order to gain a better understanding of the health care situation in Uganda, I undertook a four–week clinical shadowing experience though a partnership with Makerere University. I spent the majority of my trip at Mulago Hospital, a national referral hospital in Kampala. For three weeks, by shadowing and speaking to the physicians on the cardiology ward, I was able to learn about some specific barriers to health care, and I was able to see their effects on patient outcomes. From what I observed, the most evident burden preventing better health outcomes is the substantial lack of resources; simply, the mass volume of patients the cardiology ward admits each day overwhelms the number of physicians and nurses present, the number of hospital beds accessible, and the number of medical supplies and equipment available. Another factor preventing better health outcomes is the patients’ access to these hospitals. Because they majority of the population lives in rural areas, patients must travel a great distance to see a health professional. As a result, many tend to ignore symptoms or rely on traditional and herbal remedies. Furthermore, when patients do choose to seek medical help, they must often navigate through sub-district and district hospitals before they can be referred to a regional or national hospital that is capable of treating their condition. Ultimately, too much time elapses and prognoses become very poor. And finally, a third barrier to health care in Uganda is the high cost of medications. Although all hospital procedures are free of charge, the expenses for treatment are not fully subsidized. Therefore, many Ugandan’s cannot afford to buy the necessary medications, especially those for chronic conditions, and thus harm their prognoses. Altogether, the hospitals’ lack of resources, the patients’ lack of access to health facilities, and the costly treatment regimens make it more challenging for the people of Uganda to obtain positive health outcomes. Overcoming these burdens is no easy task, but there is hope as health awareness programs and early-screening techniques become more prevalent.
Abstract 24. An Ethical Model of International Service and Resident Surgical Training in an OB/GYN Residency Program: A Clinical Rotation in Borongan, Eastern Samar, Philippines Elizabeth W. Patton, MD Obstetrics and Gynecology is a unique field in medicine. Both medical and surgical, it is also simultaneously both a specialized area of medicine as well as a primary care specialty. In many under-resourced settings, lack of access to medical management or minimally invasive surgery for conditions like uterine fibroids or ovarian masses means that by the time the patient arrives at the local clinic, the only available intervention is surgical, often via an open surgical approach. Surgical care thus becomes primary gynecologic care. At the same time, in the United States, many obstetric and gynecology residency programs are faced with a need to provide trainees sufficient surgical training in open procedures such as hysterectomy in the face of a smaller pool of candidates needing such surgery, because of better access to medical management and minimally invasive surgical techniques available here. Given the mutually compatible needs, can an international rotation fulfill both service and educational goals while providing the patient with the highest quality care available? In February 2012 I completed a obstetric and gynecological surgical rotation at the Eastern Samar Provincial Hospital, Borongan, Eastern Samar, Philippines under the supervision of Dr. Victor Trinkus, attending physician in the department of Obstetrics and Gynecology at Stroger Hospital of Cook County (a Northwestern Obstetrics and Gynecology Residency clinical site) with the financial support of the Northwestern University Global Health Initiative. We performed over 30 major gynecologic surgeries and 2 cesarean sections, as well as performing one vaginal/breech extraction of preterm twins. We also saw many patients in the clinic setting with a variety of gynecologic complaints. In total the team, made up of not only gyn surgeons but also general surgeons, ENTs, pediatric surgeons, ophthalmologists, medical and pediatric doctors, anesthetists, and OR/ward nursing staff performed 324 surgical cases in 2 weeks in collaboration with our Philippine colleagues. The patients were drawn from Borongan itself (a city of approximately 50,000 residents and the provincial capital of Eastern Samar) as well as the entire province, and many travelled hours to reach the clinic. In the Philippines, government hospitals guarantee a bed, and a basic evaluation by staff, but patients and families must pay out of pocket for all supplies needed for surgery or treatment including medications. Therefore, many patients had waited for a year if not years for the medical team to return to perform a needed surgery. The key to the long term of success of the Borongan mission (now in its tenth year) are a close collaboration with local hospital staff, the ability to take high quality medications and anesthesia machines to provide effective and safe anesthesia, and the careful selection of cases appropriate to the setting, resources and time available. With the appropriate steps and strong relationships between visiting surgeons and local staff, international gynecologic surgical rotations can both fulfill the clinical needs of the local community while providing an exceptional arena for resident training in gynecologic surgery.