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Moving Forward in Global Health Internist-Pediatrician Christina M. Hanna (Fâ€™08, Mâ€™14) in Butaro, Rwanda
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Moving Forward Health on the Move Understanding people—and disease—in transit, with Georgetown’s Global Health Initiative
When Global Health Is Local
Christina M. Hanna (F’08, M’14)
Cross-Border Care Five alumni in global health share lessons from the field.
Mobility and Migration Mark Dybul (C’85, M’92) and Susan Kim (MBA’13)
Formation of a Global Caregiver Learning comes to life through practical experience in global health.
Georgetown students and faculty offer medical support for D.C.-area migrants and refugees.
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Check Up News & Research
Issues in Bioethics On Campus Alumni Connections
From the Archives The Red Cross ambulance station at 930 16th Street NW conducted trainings and demonstrations during the influenza epidemic in the fall of 1918. Washington, D.C. was hard hit, and public schools, theaters, city playgrounds, and churches were closed for the month of October. An influx of military personnel to the nationâ€™s capital contributed to the spread of the deadly disease, which would infect 33,000 residents and claim the lives of nearly 3,000. Library of Congress
RE A D E R F E E D B A C K
A publication for alumni and friends of Georgetown University Medical Center
HOW FAR WE’VE COME Thank you for dedicating an entire issue last year to the topic of women in medicine. I was a resident in pediatrics at Georgetown 1976-77. While on rotation at the old Fairfax Hospital, the Department of Pediatrics at Georgetown sent a photographer out to take this picture of the house staff on my service. Why? Because they found it highly unusual, and worthy of a photo and write-up, that the entire staff of two first-year residents, two second-year residents, and the fellow were all female.
Editor Jane Varner Malhotra
D’Alessandro (back, center) pictured with her pediatric colleagues at Fairfax Hospital in 1977—representing a newsworthy demographic at the time.
I continue to be astonished that many today have no idea of the conditions under which their antecedents paved the way for today’s acceptance of women in medicine; and that so few want to hear or record the many stories of institutional discrimination that applied to women in medicine “back in the day.” When I was coming up, no one could prosper in academic medicine without putting in the crazy hours that those who had gone before put in, like a rite of passage. I believe the influx of women into medicine forced the medical culture to take a more reasonable look at how one works. It is important to understand the history of progress that provides opportunities today. Gloria Grindheim D’Alessandro, MD (R’77) Charlottesville, Virginia
SURVEY RESULTS Thanks to all who responded to the magazine email survey this summer. Your input helps guide content around issues of interest to you, our valued Georgetown alumni, faculty, and friends.
Spring/Summer 2018 Georgetown Medicine magazine
“The last issue about the arts was especially outstanding,” one reader commented. Several respondents expressed appreciation for our increased coverage of medical ethics—a strong suit for Georgetown. Others would like to learn more about Georgetown’s work on the opioid crisis, physician burnout, medical student wellness, and mental health. Look for stories on these important topics in 2019.
To share your feedback, questions, story ideas, old photos, and reflections from the field, contact us at Georgetown Medicine Magazine, P.O. Box 571253, Washington, DC 20057-1253, or email us at email@example.com.
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Chelsea Burwell (G’16) Kate Colwell Giuliana Cortese (C’13, L’16) Jupiter El-Asmar (F’17) Monica Javidnia Camille Scarborough Leigh Ann Sham Seren Snow Kristina Madarang Stahl Karen Teber Lauren Wolkoff Kat Zambon
Design Director Robin Lazarus-Berlin Lazarus Design
University Photographer Phil Humnicky
Executive Vice President for Health Sciences and Executive Dean Edward B. Healton, MD, MPH
Dean for Medical Education Stephen Ray Mitchell (W’86), MD, MBA
Georgetown Medicine is published by the Georgetown University Office of Advancement Communications. Visit the magazine online at gumc.georgetown.edu/magazine. The magazine welcomes inquiries, opinions, and comments from its readers. Address correspondence to georgetownmedicinemagazine@ georgetown.edu or: Jane Varner Malhotra, Editor Georgetown Medicine Office of Advancement P.O. Box 571253 Washington, DC 20057-1253 For address changes contact alumni records firstname.lastname@example.org or 202-687-1994. For up-to-date information on Georgetown events and alumni news on campus and around the world, visit Georgetown Alumni Online: alumni.georgetown.edu. © 2018 Georgetown University
Cover photo by Alice Kayibanda
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NEWS & RESEARCH
Major Goals for Microsurgery n n
David Habin Song, MD, MBA, is on a mission to make Georgetown University School of Medicine and MedStar Health the best academic health system in the country for plastic surgery. ‘‘Plastic surgery is a field that covers the entire body, from scalp and cranial reconstruction to limb salvage,” he explains. As a surgeon he finds meaning in “restoring something that cancer or trauma has taken away.”
The field of plastic surgery is much more than cosmetic procedures, says Song, who has developed innovative techniques to reduce lymphedema in women after breast cancer surgery.
Song serves as academic chair of the department of plastic surgery at the School of Medicine and regional chief of plastic surgery at MedStar Health. In the year that he has filled these positions, Song has advanced the role of plastic surgery in the regional academic health system. Peer-reviewed research publications have grown
by 25 percent, he created a vice-chair for research position, the number of Georgetown medical students who chose to pursue plastic surgery has increased, and MedStar’s residency in plastic surgery has expanded from three residents per year to four. Clinically, Song is a well-known leader in the use of microsurgical techniques to help women who have had breast removal and excision of lymph nodes to treat breast cancer. He has developed innovative surgical techniques, which take place at the level of individual blood vessels and nerves. It takes a “disciplined set of tools” and an additional year of training, Song says, to get comfortable sewing tiny blood vessels under a microscope with sutures that are about half the thickness of a human hair. Song is also leading an effort to expand use of lymphovenous bypass and lymph node transplant. “One of the biggest side effects of breast cancer surgery is lymphedema, painful swelling of the arm caused by the removal of lymph nodes under the arm. Because these little pumps are not there to remove lymph fluid, the arm can swell intolerably,” he says. The answer, Song says, is to transplant “excess” lymph nodes from another part of the body to the armpit area, and connect them so that they can drain lymph into an existing blood supply. “This is a burgeoning field because the procedure can be used in many areas of the body,” Song says. The surgeon with an MBA is also keenly interested in improving health care delivery. “I blend a lot of operations management in health economics into how we practice medicine today,” he notes. Song’s projects include reduction of medical waste in surgery, improvement in the ergonomics of surgical practice, and health care cost reduction through methods like bundled payment for a particular surgery. n
Top photo: AP Photo/Andrew Harnik
Travel and Gut Lag Circadian rhythm and core body temperature irregularity affect more than sleep when we travel across times zones, Georgetown Family Medicine Professor Caroline Wellbery wrote recently in The Washington Post. “Beyond sleepiness at the wrong time, jet lag affects our internal organs: The liver, pancreas, heart and gastrointestinal tract have their own daily rhythms,” she says. “While these schedules are regulated in part by a master pacemaker in a tiny region of the brain, called the suprachiasmatic
nucleus, time change may affect different organs differently. The most obvious sign of this is ‘gut lag’—feeling hungry (or having no appetite) at the wrong times, experiencing constipation or having an urge to use the bathroom at unexpected times. There is even evidence that gut lag can affect the intestinal microbiome (those bacteria colonizing our gut) and make us more susceptible to traveler’s diarrhea. That’s in part because disrupting the daily rhythms of our 100 trillion intestinal microbes can impair their immune function.”
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Using Big Data to Track HIV An innovative data-sharing technology developed at Georgetown will be used to improve the National HIV Surveillance System through a $2 million grant from the Centers for Disease Control and Prevention (CDC). The surveillance system allows public health agencies and departments across the United States to monitor the dynamic nature of the HIV epidemic while significantly enhancing privacy protections. The technology also improves monitoring by quickly resolving duplicates so that HIV cases can be properly counted. The grant, administered over a five-year period, will help the team of Georgetown researchers further develop the socio-technical approach that provides advanced privacy protections by using a specially engineered system that avoids permanent storage of parties’ data. It allows no user access while processing data, and only analyzes data while it is carefully isolated in computer memory—a substantial departure from traditional approaches to data sharing and analysis. J.C. Smart, PhD, professor of computer science and the grant’s principal investigator, says the data tool’s privacy-
“Georgetown has merged a privacy-assuring technology with a highly sociological approach and successfully applied it to public health.” sensitive approach marks a major shift in the way HIV surveillance activities are conducted, and provides a framework applicable to other data-related activities. Seble Kassaye, MD, assistant professor at the School of Medicine and principal investigator of the Washington D.C. Metropolitan Women’s Interagency HIV Study (DC-WIHS), serves as a co-principal investigator on the project. DC-WIHS,
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funded by the National Institutes of Health, focuses on research that helps better understand how HIV affects the lives of women in the D.C. area. “Georgetown has merged a privacy-assuring technology with a highly sociological approach and successfully applied it to public health,” Kassaye says. “Implementing this technology in the public health sphere will allow agencies and departments to have updated, comprehensive and accurate information regarding progress toward our national HIV treatment goals to achieve high levels of viral suppression,” she adds. “This is both for the benefit of the individual as well as to mitigate ongoing transmission of HIV.” The project has allowed Georgetown to apply its academic and technical expertise to solve an important societal challenge, according to Joanne Michelle Ocampo, project director in public health informatics for the Office of the Senior Vice President for Research and Georgetown’s Medical Center. “This project is the direct result of years building collaborative public-private partnerships across public health agencies and academia and greatly illustrates how fruitful this type of interdisciplinary and cross-sectoral work can be,” says Ocampo. n
Making Sense of Sounds
Top illustration: Brian Stauffer / Bottom illustration: Shutterstock
The human brain learns both sights and sounds through the same two-step cognitive process, suggests a new study by researchers from Georgetown University School of Medicine’s Department of Neuroscience. “We have long tried to make sense of senses, studying how the brain represents our multisensory world,” says the study’s senior investigator, Maximilian Riesenhuber, PhD. In 2007, the research team—including Georgetown neuroscientists Xiong Jiang, PhD, and Josef P. Rauschecker, PhD, as well as graduate student Mark A. Chevillet (PHD’11)—was the first to describe this two-step model in human learning of visual categories. They found that neurons in one area of the brain learn the representation of the stimuli, and another area of the brain categorizes that input to ascribe meaning to it—for example first seeing
a car without a roof and then analyzing that stimulus in order to place it in the category of “convertible.” To test whether the brain uses a similar two-step process for sound, the researchers trained 16 study participants to categorize monkey communication calls—real sounds that mean something to monkeys, but are alien in meaning to humans. The investigators divided the sounds into two categories based on prototypes: so-called “coos” and “harmonic arches.” Using an auditory morphing system, the investigators created thousands of monkey call combinations from the prototypes, including some very similar calls that required the participants to make fine distinctions. Learning to correctly categorize the novel sounds took about six hours. Before and after training, fMRI data were obtained from the participants to look
for changes in neuronal tuning in the brain following categorization training. Advanced fMRI techniques such as rapid adaptation (fMRI-RA) and multi-voxel pattern analysis were used, along with conventional fMRI and functional connectivity analyses. In this way, researchers were able to see two distinct sets of changes similar to those previously found in vision experiments: a representation of the monkey calls in the left auditory cortex, and tuning analysis that leads to category selectivity for
different types of calls in the lateral prefrontal cortex. Rauschecker says these findings could one day help scientists find new ways to restore sensory deficits. “Knowing how senses learn the world may help us devise workarounds in our very plastic brains. If a person can’t process one sensory modality, say vision, due to blindness, there could be substitution devices that allow visual input to be transformed into sounds. So one disabled sense would be processed by other sensory brain centers.” n
What makes Washington different as a medical research hub? “Proximity to power, to government, to decision-making that exists on an international scale. Most other countries in the world are represented here. It’s a very diverse community that brings into it diversity of culture and diversity of thought. You’ve got places of inquiry and experience that are world-class. You’ve got representatives from some of the most influential nongovernmental agencies, like the World Health Organization. There are ways in which you can begin to discover something here and have impact way beyond D.C.” — Robert Clarke, PhD, DSc, Georgetown University Medical Center Dean for Research June 2018 Washingtonian
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New Tumor Test for Better Bladders B
The simple test may reduce overtreatment and ease high cost for some bladder cancer patients. Tumors testing positive (like A) are twice as likely to recur and invade the muscle as negative tumors (like B). n n
Georgetown researchers have developed a new diagnostic tool for bladder cancer that may reduce unnecessary treatment for patients with non-invasive tumors. Bladder cancer is relatively common, and treatment is notoriously extensive, uncomfortable, and expensive. Because early stage lesions come back in two out of three cases, patients must return for frequent monitoring of the bladder wall. Post-surgery surveillance includes cystoscopy, the insertion of a
lighted optical scope into the urethra to examine the inside of the bladder. In cases when new lesions are found, 20 percent of those patients will develop an invasive cancer. A research team from Georgetown and Denmark found that a fairly simple test significantly improves the identification of problematic bladder tumors versus noninvasive bladder lesions. The study, published in Clinical Cancer Research, validates the overexpression of the
STAG2 gene as a biomarker for early stage bladder cancer to recur, become invasive, and spread. Checking for STAG2 is a simple procedure for pathologists who routinely examine excised tumors, says the study’s senior author, oncology professor Todd Waldman, MD, PhD. His studies describe how to run the test, which could spare patients unneeded surveillance and aggressive treatment that can produce significant side effects.
Waldman and his colleagues have worked on a diagnostic test for years. This study summed up several of those clinical studies, concluding that using the test “offers additional twofold predictive discrimination,” Waldman says. “We are closer to our goal of lowering the risk of both aggressive bladder cancer and oversurveillance and treatment side effects in bladder cancer patients,” he says. “In principle, it might be possible to reduce the frequency of post-resection surveillance and therapy in patients whose cancer is STAG2-negative, and, conversely, treat patients and keep up high frequency surveillance in patients who have positive test results.” The study’s first author is Alana Lelo, an MD/PhD candidate at Georgetown University School of Medicine. n
Examining the Opioid Epidemic
The PharmedOut 2019 Conference at Georgetown University Medical Center will convene interdisciplinary and evidence-based discussions—free from pharmaceutical influence—on use of, abuse of, dependence on, and addiction to opioids. The event, running June 13-14, 2019, will take a critical look at subjects such as addiction treatment facilities, opioid marketing, medication-assisted treatments, invented diseases that prompt doctors to raise opioid doses, and alternatives to opioids for chronic pain. “This is a topic that anyone would find fascinating, regardless of their field,” says Adriane Fugh-Berman (M’88), associate professor and director of PharmedOut. “The fallout from the opioid epidemic touches us all.”
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Brain Cancer Cache
Tumor data is now easily, freely accessible to global researchers. n n
A valuable set of brain cancer biomedical data has been made freely available to researchers worldwide, say researchers at Georgetown Lombardi Comprehensive Cancer Center. Hosted and supported by Georgetown, REMBRANDT (REpository for Molecular BRAin Neoplasia DaTa) is one of only two such large collections in the country. Beyond that impressive acronym, the Georgetown data resource is unique in several ways. One is that it contains both genomic information, collected from volunteer patients who allowed their tumors to be sampled, as well as diagnostic treatment and outcomes data. Most collections contain either one or the other. Additionally, the data collection interface is extraordinarily easy to use, says Subha Madhavan, PhD, chief data scientist at Georgetown University Medical Center and director of the Innovation Center for Biomedical Informatics (ICBI) at Georgetown Lombardi. Originally created at the National Cancer Institute, the dataset was transferred to Georgetown in 2015, and is now physically located on the Georgetown Database of Cancer (G-DOC), a cancer data integration and sharing platform. G-DOC investigators, led by Madhavan, developed novel analytical tools to process the information anew. Researchers can search their gene of interest, check expression and amplification status, and link that to clinical outcomes, Madhavan says. They can save their findings to their workspace on the G-DOC site and share with their collaborators. Given the approximately 20,000 protein coding genes in the human genome, and the variety of brain cancer tumor types, “it will take a big village—really a vast metro area—of investigators to
understand the bases of these tumors and to effectively develop treatments that target them.” REMBRANDT includes genomic data from 261 samples of glioblastoma, 170 of astrocytoma, 86 tissues of oligodendroglioma, and a number that are mixed or of an unknown subclass. Outcomes data include more than 13,000 data points. n
Smithsonian Goes Viral A new exhibition at the Smithsonian’s National Museum of Natural History shows how epidemiologists work to identify and contain the spread of infectious disease. “Outbreak: Epidemics in a Connected World” explores how disease moves through increasingly intersecting worlds of animals, the environment, and humans, and highlights the social and emotional impact of epidemics including HIV/AIDS, Ebola, and influenza. Instrumental in collecting and curating the content was Georgetown’s Daniel Lucey, MD, MPH, adjunct professor of microbiology and immunology at the Medical Center and a senior scholar with the O’Neill Institute for National and Global Health Law.
He was drawn to epidemiology while working in an AIDS ward in San Francisco in the early 1980s. “Our teachers couldn’t teach us about the disease,” he says. “It was a huge inflection point for me.” The exhibit is open through 2021. A smaller-scale, customized version of the content is now on display in other cities and countries, including Atlanta, San Francisco, Finland, and India.
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Moving Forward in Global
ntering the central rotunda of the Smithsonian Museum of Natural History, formerly known as the Museum of Man according to the plaque outside the door, I was struck by the din. The din of Man. More accurately, the din of women, men, and tons of children. It’s early summer, and tourists from around the world swarm in looking for a break from the heat, and maybe something new to ponder on the way. My grandparents used to bring me here when I was a child, and it strikes me that the sound in that great hall is the same, decades later. All our voices bouncing off each other, echoing around the marble, domed chamber. Babies crying, toddlers laughing, tweens complaining, elders explaining. And the big-eared elephant in the middle has heard it all. Upstairs, visitors stream into the new “Outbreak” exhibit on epidemiology and the increasingly interconnected health of our planet. Environment, animals, and people move and intermix and impact each other, sharing good and bad— including deadly disease. How do pathogens jump from animals to people and quickly cause global pandemics and pandemonium? A 1918 Spanish flu victim’s skull offers tooth plaque for scientists to better study the biology of this particular strain. A tray of 100 tiny yellow fever-infected mosquitos are pinned down and labeled in an orderly ten-by-ten grid. The message is plain: Don’t worry! We can identify this, categorize it, control it. Photos and quotes from frontline Ebola workers during the 2014 epidemic offer a glimpse into the modern, human toll of disease outbreak. Another display chronicles the emergence of HIV/AIDS and how it changed the fabric of our society. Both in the Smithsonian exhibit and in the pages that follow, we see the efforts to comfort the afflicted and to understand disease, from the microscopic to whole-planet views. The new Global Health Initiative at Georgetown serves as a wheel hub for interconnecting research and education, covering areas of concern such as migration, pandemic preparedness, and road safety in developing countries. Georgetown’s global health work is local, too, including asylum seeker medical evaluations and primary care for refugees. After graduating, our intrepid alumni journey to Central Africa, Central America, and Central Asia, partnering to build health equity around the world for those living at the margins. As we move forward in global health, hope springs from these rising efforts to work together internationally, crossing borders to share data and resources, blurring the boundaries of division. Human ingenuity and care for the greater good—so we can all enjoy the din. Jane Varner Malhotra Editor
Health on the Move Understanding people—and disease—in transit By Lauren Wolkoff
ne hundred years ago, the world faced a relentless and devastating foe. It marched across the globe, claiming the lives of 50 to 100 million people. It was the 1918 Spanish Influenza—one of the deadliest and costliest pandemics in human history. Today, the flu still tops a growing list of global pandemic threats—infectious diseases that wreak havoc on people, health systems, and economies. The number of known emerging infectious disease outbreaks has increased four-fold in the past 60 years, and recent examples of new or resurgent diseases abound: SARS in 2003; H5N1 in 2007; H1N1 in 2009; MERS in 2012; Ebola in West Africa in 2014; Zika in 2015; and the re-emergence of yellow fever in 2016. On the one hand, we are better off than we were a century ago. We know more about how diseases spread, our diagnostic tools are sophisticated, and the internet and social media have proven useful as early detectors of outbreaks in remote pockets of the globe. In addition, the global health community has made great strides in shoring up countries’ public health infrastructure, capacity, and emergency management systems. On the other hand, there are new variables to contend with that make us more vulnerable to the spread of disease. Consider trends such as a highly globalized and interconnected global economy, ease of travel, urbanization, migration, and displacement. People, organizations, and goods are increasingly on the move—and with them go diseases and other health considerations. Across Georgetown, a community of researchers, educators, clinician-scientists, and students are thinking about the ways in which individuals and populations are moving—and how diseases and chronic public health concerns are moving with them.
If the world has learned one thing from the past century, it is that pathogens do not recognize borders—and they spread more quickly than ever. It’s now a common refrain that an infectious disease that emerges in one remote village can spread to urban centers on every continent within 36 hours. “Right now we have the largest number of people on the move throughout the world since World War II,” says Rebecca Katz, PhD, MPH, who directs the Center
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A Moving Target
At work in Beijing, Bouey stands at the crossroads of transnational public health and pandemic preparedness research.
Katz works on global health security challenges like the emerging Ebola outbreak in the DRC.
for Global Health Science and Security at Georgetown University Medical Center. “There are many implications of this movement, geopolitically and from a policy standpoint. But from a disease perspective, it brings a whole new set of complex challenges.” Katz is in good company in looking at these issues. The Georgetown Global Health Initiative (GHI) is a university-wide platform for collaboration—linking people across schools including the Medical Center, the Law Center, the School of Foreign Service, and the McCourt School of Public Policy—to study the world’s most pressing global health challenges. By its very nature, global health demands a multidisciplinary approach—the ability to examine longstanding and emerging challenges alike through the lenses of health, science, law, ethics, business, economics, diplomacy, and anthropology. Adding to this complexity is the fact that, while global health transcends borders, it also is highly context-specific. An intervention that works well in one community or country may not work at all elsewhere—for a variety of systemic, political, or cultural reasons. And for people like refugees who are on the move, it may not be evident where responsibility for their health lies. “How do we conduct effective disease surveillance in a population that is hard to keep track of, and when it is unclear who governs them? There are international legal obligations for disease reporting and response, but it is not clear in a refugee camp who is responsible for these activities or how surveillance and response can be operationalized,” Katz says.
‘Hidden’ Populations Whether they are relocating from a rural area to a city, being forcibly displaced from their homes, or seeking new economic opportunity, migrants and refugees present enormous challenges for global health security experts. One prominent example of the relationship between migration and pandemic preparedness is China’s Guangdong province, a hub for international trade and commerce. A group of researchers led by Jennifer Huang Bouey, PhD, MPH—an associate professor of epidemiology in the Department of International Health at Georgetown’s School of Nursing & Health Studies—is collaborating with Chinese colleagues to analyze this fascinating and complex case study. Known as the U.S.-China Global Health Working Group, the multidisciplinary effort is co-led by Bouey and Cheng Feng, a professor at Tsinghua University in Beijing, with participation from an array of U.S. and Chinese researchers, including Katz and Michael Stoto, PhD, professor of health systems administration and population health at NHS. After Guangdong gained notoriety in 2002 for being home to the first reported cases of severe acute respiratory syndrome, or SARS, the Chinese government began to invest heavily in
surveillance, emergency preparedness, and public health system restructures to address what many criticized as a fundamental lack of readiness and transparency. Despite these measures, one major vulnerability remains in China’s pandemic preparedness, according to Bouey. Guangdong is increasingly a draw for international migrants seeking work, particularly from Africa and Southeast Asia, who remain unaccounted for by official systems and therefore “hidden” from policy. There is no formal mechanism to track international migrant laborers in China, including who is entering the country for factory work, how long they are staying, and where they go once they enter, Bouey says. “As public health researchers, we see risk factors of disease transmission in migration patterns and how people move from place to place,” she says. “The fact that the international migrants go underground and become marginalized poses a threat to the public health system—there is a significant barrier to reach these people through traditional surveillance or response channels, and it is hard to provide the necessary basic health care services for those in need.” Caring for migrants and tracking disease patterns in this population is difficult for local public health officials, Bouey says. “We know it’s a ticking bomb.”
Mobility Upward While people often migrate out of economic necessity or because they are forced to relocate, movement can also reflect economic progress—progress that is tied to better health outcomes. Rates of extreme poverty have fallen in the last 40 years, “mostly in China and India, but increasingly in many other parts of the world too,” said development economist James Habyarimana, PhD, the Provost’s Distinguished Associate Professor at Georgetown’s McCourt School of Public Policy. Habyarimana contends that market forces are heavily tied to movement, which in turn is tied to public health. As markets for certain goods and services expand and change, people migrate in pursuit of new opportunities—and for every action, there are multiple reactions. For example, he notes, expansions in transportation infrastructure in developing countries have led to improved integration between rural and urban areas, promoting both greater traffic flow as well as the growth of major capital cities such as Nigeria’s Lagos, Kinshasa in Democratic Republic of Congo, and Dhaka in Bangladesh. Meanwhile, the increased demand for elder care in the developed world has led to considerable migration of nurses and other health professionals from the developing world. “Progress is intricately tied to connections between people and places—and to people moving to opportunity,” Habyarimana says. “And the types of things that kill people when they are poor are very different from the types when they
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Economic progress and public health depend on the safe and efficient flow of goods and people, says Habyarimana.
get richer—the so-called epidemiological transition describes the shift in primary health challenges from infectious to noncommunicable diseases as societies become richer.” These noncommunicable diseases—such as hypertension, diabetes, cancer, and mental health disorders—can be associated with economic growth, exposure to more congestion in cities, and lifestyle changes including diet and level of activity. These chronic health conditions are also increasingly observed among low- and middle-income populations, who tend to be disproportionately affected by economic shifts linked to increased migration to cities, longer work days, and more financial stress. Though the long-term impact on health, communities, and economies can be enormous, noncommunicable diseases receive less international attention—and thus less funding—than infectious diseases. Policymakers and donors are much more motivated to stop the spread of a killer pathogen than they are to try to untangle the causes, comorbidities, and implications of chronic illness. The impact of heart disease in an individual or community is much harder to isolate and quantify than the impact of Ebola, for example.
Global Agendas Scholars increasingly recognize that these two global health priorities—strengthening global health security and combatting chronic disease—are not only compatible, but fundamentally interdependent. It comes down to resilience: how strong a population is to begin with will have great bearing on how it responds to urgent health threats such as an infectious disease epidemic. As a result,
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many experts view efforts to ensure populations have universal health coverage as an investment in global health security. A working group born out of collaboration between Katz’s center, Georgetown’s O’Neill Institute for National and Global Health Law, and the University of Edinburgh Global Health Governance Programme, is exploring the question of whether these two global agendas are aligned and where they might diverge. Besides Katz, Georgetown collaborators include Lawrence O. Gostin, university professor and faculty director of the O’Neill Institute, and anthropologist Emily Mendenhall, MPH, PhD, associate professor of global health in the Walsh School of Foreign Service. As the group studies how chronic disease prevention relates to global health security, one connecting thread is clear: the importance of funding.
Follow the Money In today’s uncertain global health funding climate, making the most of every dollar is key. That is why, besides studying the flow of people, Katz and her collaborators are also looking at the flow of funds. They have developed a new tool, called the Global Health Security Funding Tracking Dashboard, to track direct foreign investments and private foundation funding globally with the aim of surfacing gaps and eliminating redundancies. Mapping the flow of funding against the burden of disease is complicated, and it’s an incomplete picture at best without considering the flow of power and influence. “It is never as simple as countries investing in other countries with the highest disease burden. Foreign investment results
from a combination of disease burden, diplomacy, trade, and the ability of a country to effectively use aid—all are factors that influence relationship-building and soft power,” Katz says. In other words, geopolitics can be the 800-pound gorilla in the room when talking about global health security. It is why political transitions, ruptures in diplomatic relationships, and shifting regional alliances can upend years of global health policy. “So much of foreign aid is relationship-based,” adds Katz.
Images of Africa Photobank / Alamy Stock Photo
People at the Center What is largely missing in these conversations around global agendas and funding is “people’s lived experiences,” according to Mendenhall, a medical anthropologist. She studies a concept known as syndemics, a combination of “synergy” and “epidemic,” that looks at how diseases cluster together, the biological or social interactions that cause them, and the large-scale social forces that underpin pandemic diseases. “At the heart of all this is real people’s lives. Yet their stories are fundamentally overshadowed by the discussion of global agendas,” Mendenhall says. People on the move carry highly complex health conditions or illnesses with them that are not only multimorbid, but also can be born of or exacerbated by social conditions. A person’s metabolic system, for example, is affected by stress and chronic financial and food insecurity. It is impossible to separate life events and circumstances from physical well-being, according to Mendenhall. “Historical trauma, subjugation based on gender, race, or class—these cause extreme stress in people’s lives,” she notes. “Some people call these ‘life lesions,’ and they manifest in your body. They are something you carry with you across the border.” To talk about the implications of movement on health, one must also consider the conditions that prompted that movement. The trauma of war, abuse, extreme poverty can show up right away, or it could take years to materialize as mental and physical illness. Either way, as people move, the health manifestations of these events move with them. Occupational risks are another vital piece of the puzzle. For many, migration offers the promise of a better economic outlook or social standing, even if they have to take low-wage, high-risk jobs to make ends meet. As such, economic migrants who come to the United States—particularly those who are undocumented—face extraordinary occupational hazards in high-risk industries such as construction and agriculture. Moreover, many who work in these fields may not report injuries for fear of losing their jobs; the power dynamic is heavily skewed towards the employer. “The big issues that overwhelm everything else are people’s fear of job loss and their fear of being deported,” says Rosemary Sokas, MD, professor of human science and family medicine at NHS. “Between these two things, workers will likely end up
Simple Ways to Safer Roads
ne important health consequence associated with increased mobility is often neglected—even though it factors among the fastest growing threats to global health. As countries become wealthier, residents seek increased mobility, and more vehicles and drivers hit the roads. In the absence of adequate and enforceable safety regulations, more traffic produces greater injuries and fatalities. In fact, the World Health Organization predicts that road fatalities will become the fifth leading cause of death worldwide by 2030. The threat is particularly acute in less developed nations that have weak infrastructure and often weaker traffic regulations. James Habyarimana, PhD, and fellow Georgetown economist Billy Jack, PhD, have led undergraduates in research and fieldwork to test low-cost, low-tech interventions in Kenya to promote road safety and curb traffic fatalities in the public bus sector. What they have found is that often the simplest measures can be the most effective—and cost-effective. Their Kenyan experiment has been scaled up, transforming into a campaign called Zusha! which means “Protest!” in Swahili, that deploys stickers to encourage public minibus passengers to speak up if the driver is being reckless. Now Habyarimana and Jack are working with regulatory organizations, including the National Transportation Safety Authority, to integrate this low-cost strategy into the country’s road safety programs. “We are finding that the gap between the rich and poor countries really is mostly about behavior that results from poor enforcement of regulations,” Habyarimana says. “I’m motivated by research in which I can find little tweaks that have big impacts. Spending on programs to promote safer behavior on roads is one of the most cost-effective investments we can make in global health.” n
putting up with almost everything, are unlikely to report when things do go wrong, and feel powerless to try and change anything,” Sokas, an expert in occupational and environmental health, sits on the Board of Directors of the Migrants Clinicians Network, a nonprofit organization that works to train and support health centers, health outreach workers, clinicians, and other care providers who work primarily with migrant workers or other mobile, underserved populations.
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Care of the Whole Person An examination of people and disease on the move requires both a macro and micro lens. It demands a high-level policy perspective grounded in an understanding of social and economic determinants of health. It is at once top-down and bottom-up. This seeming polarity exemplifies the Jesuit value of cura personalis, care of the whole person. This means considering a person’s entire being, including where they live, where and how
they move, how they impact their community, and how their community impacts them. It is what excites researchers like Mendenhall, who was inspired to study medical anthropology through reading about liberation theology from renowned Jesuits such as Gustavo Gutiérrez and Oscar Romero. “People’s health is always based in historical, social, and economic contexts. We must think about people’s health as being inextricably tied to their life and their existence,” Mendenhall says. “Health is fundamental to living a good life.” The interdisciplinary approach needed to grapple with these challenges has found a fertile home at Georgetown through efforts like the Global Health Initiative, which earlier this year launched the Great Influenza Centenary Project. Spanning campuses and a variety of disciplines, the project draws on reflections from the 1918 pandemic to inform response to current pandemic challenges. This comprehensive approach is not just beneficial for the study of today’s thorniest global health challenges—it is essential. “These issues are so complex, so multi-dimensional,” says Katz. “You need all types of people with all types of expertise and interests to dive in—it’s how at an institution like Georgetown we can be at the forefront of shaping these conversations.” n
Medical anthropologist Mendenhall studies syndemics—the clustering of social conditions and diseases—to better understand and address human suffering.
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Photos on pages 12, 14, and 16: Lisa Helfert
She has collaborated with them on research to identify and address barriers to the recognition, management, and prevention of work-related illness or injury among migrant populations. Sokas cites as an example the case of a 30-year-old immigrant construction worker with diabetes. He had bought himself a pair of new work boots, which caused blisters, but he continued to work. Because of his diabetes, he developed osteomyelitis, a rare but serious bone infection. He ultimately needed intravenous drug therapy and nearly lost his foot. “It was one of those examples where he couldn’t take time off from work, and he powered through because he needed the income. There is no replacement for that income, no sick leave, and you can see how this all has terrible consequences for an individual in these circumstances,” Sokas says.
FACULTY POINT OF VIEW
Mobility and Migration By Mark Dybul (C’85, M’92) and Susan C. Kim (MBA’13)
e are in an exciting, and challenging, time in global health. Progress has been made to shift the disease burdens of infectious and tropical diseases. Once deemed impossible, we are close to ending the epidemics of HIV, polio, tuberculosis, and malaria, and are making headway in the response to non-communicable diseases—the leading cause of death worldwide. But global health is at a critical inflection point. We are confronted by urgent trends that demand innovative response. One such megatrend is migration. The movement of people and ideas is no longer limited by physical barriers, though political borders remain. The United Nation reports that last year 258 million people moved across borders, up by 85 million from 2000. While 26 million of the migrants were refugees, the vast majority had moved from their country of birth in search of economic mobility, hoping to improve their financial standing. To properly respond to issues of global health for all migrant populations, we must broaden solutions beyond short-term policies to more comprehensive, long-term responses in health systems, education, employment, and housing. Moreover, global health security is inextricably linked to the issue of increased migration. Epidemic outbreaks can have catastrophic human and economic consequences, shattering the political and economic stability of affected countries, and creating shocks that reverberate throughout the global economic system. For example, in the aftermath of the 2014 Ebola crisis, the hardest hit countries of Guinea, Liberia, and Sierra Leone saw an ensuing loss of annual GDP growth around 90%. Similarly, the World Bank estimates that the potential global economic impact from a severe flu pandemic such as the Spanish Flu of 1918 could be close to $4 trillion today. Additionally, the future stability of fragile states could largely depend on health. For example, North Korea is combating a deteriorating health infrastructure, chronic malnutrition, and an epidemic of untreated drug-resistant tuberculosis, which may lead to health and migration challenges throughout the region and the world. Artificially restricting the free flow of people, goods, and ideas has never been a tenable response to global health security. A better option is to embrace the inherent value of a more interconnected world and recognize that disease outbreak anywhere threatens people everywhere. As such, wherever people move, they must have good health services. The World Health Organization, through the International Health Regulations and Pandemic Influenza Preparedness Framework and current focus
on universal health coverage, is helping build resilient health systems with effective monitoring and response capacities in the countries that need them most. Expanding the mobility of ideas to keep pace with emerging innovations is equally urgent. The preceding decades in global health have led to significant progress in harnessing technology and data for improved knowledge sharing. The drive should be towards open-source, real-time (or near real-time) online tools. One such project that our center is working on, supported by the Bill & Melinda Gates Foundation, examines how to help countries develop more effective systemic responses to their HIV burdens. Highly promising innovations occurring in discrete communities are frequently not connected to national policy, which leads to a lengthy implementation gap. Data challenges emerge when local contexts are not clearly understood, leading to over-collection, competing datasets, conflicting information systems, and duplication of efforts. Groups often do not focus on making data accessible or useful to decisionmakers and implementers. This leads to the failure to systematically review available data to develop programs with maximum impact, and the failure to generate data that intentionally directs policy. To respond to these issues, our project: (1) links existing or new communities of practice across a health system—from the community level all the way through to the policymaker level, (2) has data tailored to the needs of each community of practice, and (3) uses human-centered design methodologies to facilitate innovation and capacitate links across a health system. We will be supporting country partners in Eswatini, Kenya, and Malawi to develop an overarching, more coordinated process for health impact—ultimately, a more community-led, human-centered, and better-connected system for health innovations and care should lead to sustained improvement in health outcomes. In this time of economic and political change throughout the world, we have the opportunity to build on the success of the previous decades. But to do so, we must be bold, thoughtful, and strategic in developing solutions to confront the new challenges we face together in global health. n Mark Dybul, MD, is professor of medicine and faculty co-director of the Center for Global Health and Quality at Georgetown University Medical Center. Susan C. Kim, JD, MPH, MBA, is an assistant research professor of medicine and executive director of the Center for Global Health and Quality.
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Formation of a Global Caregiver Learning comes to life through practical experience in global health By Mike Unger and Jane Varner Malhotra
hen Kevin Bushey (M’18) was applying to medical schools, choosing one with strong global programs wasn’t an afterthought—it was a requirement. As a Filipino-American, Bushey felt strongly about taking part in an international rotation, and he wanted to do it in the Philippines. Before graduating this spring, he spent a month working at Mary Johnson Hospital in Manila, an experience he says will change the way he practices medicine for the rest of his life. “It was incredible for a number of reasons,” the Minnesota native says. In addition to helping him understand how medical practice differs between the Philippines and the U.S, his experience made classroom learning come to life. “I had the opportunity to see and manage tropical diseases I had only read about. And it was a cultural immersion—it gave me an opportunity to learn another language, to see how other people live and what challenges they face in their community.”
Impact Through Immersion As technology continues to virtually shrink our world, global health education has become more and more important, both to students and educators. “Health is an inherent human right,” says Irma Frank, DDS, senior associate dean for international programs in the School of Medicine. She defines global health as understanding how different populations approach providing equity in health care. That understanding comes from a variety of methods, including immersion, research, and structured education. Across the university and across disciplines, students take advantage of meaningful opportunities to explore global health through hands-on experiences abroad. Through the School of Medicine’s Office of International Programs, Frank helps place students around the world to do rotations or to conduct research. These international electives are offered for medical students the summer after their first year and during their fourth year. This summer, for example, 10 students who just finished their first year went to Santiago, Dominican Republic, to work with the Institute for Latin American Concern, where they
provided medical assistance to the underserved population. “To fully understand the health care systems in other countries, it is very important to have a practical experience abroad,” Frank says, so that students can witness the different ways physicians with varying resources and challenges care for their patient populations, and then reflect on the experience. “This process creates a stronger drive for students to maintain a global perspective in their own careers,” she notes. “With improved technology, the students have been able to maintain relationships with the people they worked with abroad.” In recent years, there has been a greater interest in global health among incoming medical students, Frank says. Many request an international elective, conduct independent international research, and participate in a growing number of student groups related to global issues such as infectious diseases and refugee health. In fact, now many students arrive for medical school at Georgetown with some global health experience already, whether in the U.S. working with international populations or overseas through undergraduate programs like those offered through the School of Nursing & Health Studies (NHS). When it began in 2002, the global health program at NHS was one of the first of its kind in the country. The curriculum focuses on comparative health systems, epidemiology, demography, health promotion, and maternal and child health, says Bernhard Liese, MD, DSc, MPH, chair of the Department of International Health at the school. In recent years it has also incorporated the political dimension of global health, both from a governance perspective and from an economic one. He cites tobacco use and sugar consumption as examples. “Everybody knows that tobacco causes cancer. What has the international community done to deal with the tobacco industry? And what about sugar-sweetened beverages? International health regulations, occupational health issues, pandemic preparedness issues—these issues cut across all nations.” Undergraduates majoring in global health in NHS are required to spend a semester doing research or policy work abroad. The program serves as a senior capstone and grants
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students the opportunity to conduct research projects in conjunction with NGOs, universities, and health ministries in other countries. Students have studied heart disease in Australia, HIV in Brazil, and vector-borne diseases like dengue fever in India. It’s a huge undertaking, but one that demonstrates how vital the school believes an overseas experience is for a student.
Students have studied heart disease in Australia, HIV in Brazil, and vector-borne
Meaningful Mentorship Hannah Kelly (NHS’18) spent the fall 2017 semester in Korogwe, Tanzania, a rural town in the northwestern part of the country. She worked at the National Institute for Medical Research (NIMR) studying maternal and child health, but she also incorporated a qualitative component to her work, spending time in the labor and delivery ward of a local hospital. She cites her time being mentored by a nurse named Margareth as having a particularly significant impact. “Margareth took her mentorship to the next level, calling me ‘mydia’ which means daughter as she answered all of my questions about her work,” says Kelly, who plans to attend medical school. With Margareth as her guide, Kelly participated in morning rounds, observed vaginal and cesarean deliveries, and learned about all aspects of obstetrical care in Tanzania. “Margareth was also my guide as I navigated hardships I witnessed in the delivery ward,” Kelly notes. “I was able to grasp the Tanzanian perception of life and death through our conversations, which prepared me for the shock of the deaths I witnessed in the hospital. Having such an invested mentor was an invaluable experience. Margareth’s maternal-like guidance and openness allowed me to explore her perspective as a health worker, which in turn affirmed my desire to pursue medicine.” Kelly was struck by the lack of resources at the Korogwe hospital. With no X-ray or CT machines, doctors had limited
diseases like dengue fever in India.
non-surgical options for diagnosing people suffering internal pain. Electronic medical records are virtually nonexistent there, so most patients came to the hospital with their medical history jotted down on a piece of paper, she recalls.
A Gold Mine of Experience Michael DeLuca (NHS’09, MS’15, M’16) developed an interest in international health even before he came to Georgetown as an undergraduate. “I did a gap year working in clinics in Ecuador, Peru, and Costa Rica,” recalls the emergency medicine resident at Massachusetts General in Boston. The experience inspired him to start a small charity providing medical equipment for rural health care in Ecuador and Nicaragua. He entered Georgetown as a biology major, but switched to the School of Nursing & Health Studies when he learned about the international health major.
Studying Global Health at Georgetown Undergraduate:
BS in the Biology of Global Health This degree from the College’s Biology Department offers undergraduates training and research opportunities around the science of global health and the social and environmental factors that impact vulnerable populations. BS in Global Health This degree by the Department of International Health at NHS trains students in the fields of public health, political economy of health, health science, and health systems management.
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Science, Technology and International Affairs Major, Biotechnology and Global Health Concentration Housed in the School of Foreign Service (SFS), this major concentration focuses on the biotechnology revolution, emerging infectious disease, technology’s role in health care systems, and health equity.
Executive Master’s in Health Systems Administration This NHS program offers a global Experiential Seminar focused on comparative health systems. MS in Biohazardous Threat Agents and Emerging Infectious Diseases This master’s program, offered by the Department of Microbiology and Immunology in the Medical Center, trains students in biodefense against natural and man-made threats and disease agents.
As part of his study, he worked on a project in central Ghana with a gold mining company that set up a malaria control program. “Most of the overseas internships are in public sector institutions like ministries of health, but this was with a private company, and in a gold mining camp. It was a unique place,” he says. “Thousands of people. A mass of humanity, mostly single men, working hard and not making much money. Things could be kind of volatile.” In this environment, DeLuca’s job was to measure how the community was responding to the anti-malaria program, which he describes as somewhat invasive. “The chemicals were safe, but they were spraying in people’s homes. It was contentious,” he explains. “But by improving malaria treatment, increasing education on prevention, and removing standing water, they were able to reduce cases by 70 percent. It was an aggressive program, but they forged relationships with community leaders, and they developed a radio program for people to call in to ask questions or file complaints. My role was to look at themes in those call-ins, and look for concerns for potential sources of resistance.” The program’s remarkable results, including a decrease in both mortality and hospitalizations from malaria among workers and their families, also saved the company money. After he returned to Georgetown, he received a grant from the Cosmos Club Foundation to conduct a cost-benefit analysis of the program, looking at impact both on the company and the community. Before embarking on their practical research trips, NHS requires international health majors to take a research methods course and another in community-based learning. The goal is to establish a solid theoretical knowledge and prepare students for the range of experiences they may encounter. The students participate in both an overseas and a domestic internship, which DeLuca cites as valuable stepping stones for NHS graduates,
pivotal to his career as well as important to him personally. After college he worked in international development for USAID projects in southern and eastern Africa, helping countries track health care spending and resource allocation. He returned to Georgetown to earn his MD as well as a masters in biohazardous threats and infectious diseases. “I’m now looking to combine my interest in the macro, global health sector with the individual patient care I do as an ER doc,” he says. “In policy development and research in global health security, I can be the clinical voice in the room.”
New Perspectives For his part, Bushey says his time in the Philippines has helped in the transition to his internal medicine residency at the University of Nevada-Las Vegas, where there is a sizable Filipino population. He still chats weekly with many of the residents, interns, and attending physicians he worked with in Manila, and hopes to return in some capacity in the future. That’s exactly the outcome Georgetown wants, say two of the university’s global health leaders. “The perspective gained from the practical experience abroad is invaluable,” Frank says. “It is our hope that this knowledge of other countries is reflected upon and put to use in our students’ own careers. This knowledge allows students to apply the best medical techniques they have been exposed to, whether it is domestic or international.” “We look at the world from our own perspective, but we sometimes need to change the paradigm and step into the shoes of other people and look at the world from a different perspective,” Liese says. “It is extremely important to open the aperture of the students and say, look, diversity and experiencing a different culture is a blessing. It is really enriching to your life.” n
Master of Global Human Development This practitioner-focused program offered through SFS prepares students for a wide range of careers in the development field.
sectors with their JD (or a first degree in law from outside the United States) and strong interests or backgrounds in global and domestic health laws and policies.
Master of International Development Policy This McCourt School of Public Policy program emphasizes evidence-based policymaking and program evaluation for development professionals.
LLM in Global Health Law and International Institutions This program, jointly run by Georgetown Law and the Graduate Institute of International and Development Studies in Geneva, Switzerland, is open to highly qualified candidates in public and private sectors with their JD (or a first degree in law from outside the United States) and strong interest or background in global health law and policy.
LLM in Global Health Law This program, housed at Georgetown Law, is open to highly qualified candidates in public and private
MS in Global Health This interdisciplinary degree, based in the Graduate School of Arts & Sciences, emphasizes a development-oriented approach and focuses on quantitative, qualitative, and applied social sector research in developing countries. PhD in Global Infectious Diseases An interdisciplinary, doctoral-only degree program, the PhD in global infectious diseases prepares students to address the spread and treatment of infectious diseases through laboratory and population science.
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ALUMNI POINT OF VIEW
Bridging Cultures A
s an orthodox Christian Egyptian growing up in Ballwin, Missouri, I was well aware of what it felt like to be an outsider. Until college, I had always been the only Egyptian student and the only Orthodox Christian in my entire school. Fitting in with my American peers was made more difficult by my parents’ decision to raise my brothers and me in an Egyptian microcosm. For a long time I struggled with how to reconcile these two very different areas of my life. And this struggle played into most of my whirlwind Georgetown experience. I entered as a biology major in the College, but after my first semester transferred to the School of Foreign Service (SFS). The Science, Technology, and International Affairs (STIA) major was a great fit, allowing me to study international health from political, economic, and socio-cultural viewpoints through STIA’s interdisciplinary approach. I started to look at my mixed cultural background as an advantage rather than a hindrance. It is a blessing and a skill to be able to understand two cultures so well. I saw that having to learn about American culture had increased my desire to learn about other cultures. I continued to take pre-medical courses, and in my sophomore year became the first student from SFS to be accepted
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early to Georgetown University School of Medicine. As I could finally see the end of my international affairs undergraduate studies and the start of a medical career, I was continuously asked how I would merge these two seemingly disparate interests. My answer was always the same: global health. I deferred medical school for one year to pursue a Fulbright Fellowship in Egypt. For the first time I was working and living in my parents’ country of origin, carrying out a research project to prevent tobacco use among urban street youth. Working youth are a rapidly growing population in Egypt, and they have an extremely high smoking rate. They have little access to health and other services provided to in-school youth, including access to behavioral health campaigns. I had spent months developing a questionnaire to determine the knowledge, attitude, and beliefs behind smoking practices, in an effort to discover population-focused interventions to prevent this vulnerable group from engaging in such risky behavior. While my Fulbright experience had been driven by a belief in health as a basic human right, issues of gender inequality, censorship and religious intolerance presented themselves throughout my research experience. I felt overwhelmed by the
By Christina M. Hanna (F’08, M’14)
bureaucracy, poor health infrastructure, and inadequate resources in Egypt. And I came face to face with the broader aspects of health and related psychosocial issues—poverty, abuse, and neglect. My questionnaire was lost amidst the din, and my sense of failure had never been more pronounced. During a break in December, I sought refuge back home with family in the U.S. while I tried to refocus my goals for the fellowship. It was in the airport on my way back to Cairo that I stumbled across the book Mountains Beyond Mountains, which traces the work of Dr. Paul Farmer as he establishes the health and social justice organization, Partners in Health. His challenges with the Haitian health system resonated with me. I was captivated by his endless quest to cure infectious disease from country to country—Haiti, Cuba, Peru, Russia. I could see his efforts (including the missteps and failed attempts) to promote accessible and equitable health care without distinction as to race, national origin, gender, or income level. He was trying to transform health care globally by focusing on the poorest and sickest. And it was not far from the Jesuit mission of “men and women for others” that I had been imbued with during my time at Georgetown. In fact, it was the inspiration I needed to return to Egypt with a renewed sense of purpose. As I began to build relationships with a small group of street youth in one of Cairo’s many slums, I engaged them in discussion about the issues that mattered to them and ways to address them. The focus of my project shifted from tobacco prevention to the identification and strengthening of the resiliency factors these children needed in their daily lives. At the Al-Darb Al-Ahmar youth center, run through the renowned Aga Khan Foundation, we used drama to engage the youth. This gave the children a voice—so important for youth generally and for vulnerable youth in particular. In their own words, through their own creativity, they linked their daily experiences with their health, their behavior, their lived poverty. One of the boys worked for a dry cleaner who was notoriously abusive. He would be yelled at, hit, driven out of the store for his incompetence, and not allowed to take breaks. The boy’s mother had just died of breast cancer and he was supporting his siblings, which made quitting the job unthinkable even though he hated working there. He brilliantly channeled all this into a comical skit about a boy who would daydream of going back to school or finding another job, and one day he was day dreaming while ironing and burned an iron-shaped hole in a customer’s shirt. The embarrassed owner and the furious customer began yelling at the boy, who thought quickly and calmed them down enough to say that actually this style of shirt was the latest fashion in Europe. He put his head through the burned hole, slipped his arms through the sleeves, and wore the shirt like a poncho. The customer, not wanting to lose face, said he had heard of it and paid the owner for “updating” the shirt to a “trendier” look. The vignette was charming, funny, and shed light on difficult
work conditions—showing both the necessity of the job and the ingenuity of the child. Telling their own stories enabled the youth to expand their horizons beyond daily life. Seeing them proudly perform these small vignettes for members of their community was the moment I realized how to put Georgetown’s guiding Jesuit tradition of cura personalis—care of the whole person—into practice. My experience in Egypt cemented my mission for serving the health needs of vulnerable and young populations in the United States and globally, linking curative and preventative care through community health. I have worked in South Africa, Costa Rica, Botswana, and Rwanda, where I am currently helping to carry out an intensive national pediatric leukemia treatment protocol with Partners in Health. I completed an internship with the World Health Organization, a Master’s of
(Opposite) In the pediatrics ward at Butaro Hospital in northern Rwanda, Hanna works as a clinical advisor and researcher through Partners in Health, helping to implement a more intensive leukemia protocol. (Above) Hanna discusses scans with PIH colleague Catherine Kigonya, MD.
Public Health from Johns Hopkins University, a Health Justice Certificate from Georgetown and a combined Internal Medicine and Pediatrics residency from the University of Pennsylvania. This was the path I envisioned when I made the decision to major in STIA, and a steadfast commitment to this dream over the last ten years made it possible. There were many moments when I was overwhelmed by the ambition inherent in the course of study I chose—moments when I was unsure about my ability to handle it mentally, emotionally, and even physically. My desire to become a good doctor, to affect change on the individual and population levels, and to focus on health justice and helping underserved and vulnerable populations has kept me going through the challenges. n
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Cross-Border Care By Jupiter El-Asmar (F’17)
Despite an increasingly interconnected world, where culture, finances, and people spill over porous borders with relative ease, access to high-quality health care remains stubbornly inconsistent. In many countries, including the United States, the gap between the wealthiest and the poorest continues to widen, and medical challenges facing some of the neediest communities go unaddressed. The complexity and size of the global challenge makes it difficult to find solutions. But for these five intrepid citizens of the world, merely watching from the sidelines is not an option. Whether at home or abroad, they are making their impact on some of the world’s most underserved patient populations.
In Oregon or Kenya, Care at the Margins Teresa Gipson (M’94) did not originally plan on becoming a doctor, let alone an international physician. Hailing from a diverse community in Los Angeles, she was a registered nurse but wanted to provide a deeper level of care. Despite the significant cost, Gipson decided to attend medical school at Georgetown but continued to practice nursing at the university’s hospital to help fund her medical education. Even before coming to Washington, D.C., she knew family medicine would be her specialty. “I was interested in that full spectrum of health care. At Georgetown, people often think anesthesiology, cardiology, surgery,” she says. But she notes that in rural environments, there’s much more demand for “cradle-to-grave” care from family medicine physicians. A National Health Service Corps scholar, Gipson had long been interested in working with medically underserved communities. She recalls inspiring faculty members at Georgetown including the late Angelo D’Agostino, S.J., and Jon O’Brien, S.J. “They were dedicated as physicians and immersed in their faith and the spirit of their work. They transformed their faith into action.” A 1993 medical school rotation took Gipson to Kenya and sparked 20 years of work organizing short-term medical relief there and running a clinic in the slums of Nairobi. From her home in Oregon, she coordinated a global health elective which brought medical students and nurses to Kenya on rotations. The program flourished until the 2014 Westgate Mall bombing in Kenya, when it was stopped due to safety concerns. All the while, she continued to serve the marginalized at home. After a residency in family medicine at Oregon Health Sciences University (OHSU), Gipson worked primarily in community and migrant health clinics in Oregon. Even domestically, she says, resource management posed a significant challenge.
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Today Gipson is a family medicine physician with the Peace Corps in Malawi, caring for volunteers who range in age from 21 to one woman in her 80s.
Alumni share lessons from the field “In Oregon I worked with farm workers who didn’t have a lot of money or resources. Finding people the health care they needed and the resources to actually treat people in the way that they should be treated was one of the big challenges,” says Gipson. “That looks very different in Oregon than in Kenya, but there are ways it’s the same. You make difficult decisions about how you’re going to utilize your resources, and you do the best you can.” She left Oregon briefly to pursue a fellowship in family planning and reproductive health at the University of Rochester and a Master’s in Public Health at Johns Hopkins University, but returned to serve on the OHSU faculty. Today, Gipson is stationed as a Peace Corps Medical Officer in Malawi. She oversees care for all Peace Corps volunteers there, mitigating tropical disease risk, developing strategies for providing care in the context of local health services, and planning extrication procedures for emergency situations. Although she works with a relatively healthy population, Gipson sees a lot of environmental and mental health cases. “Volunteers often have issues integrating into a new culture while living in villages with no electricity or running water, and trying to learn a new language and job,” she says. To reach distant patients, she practices telemedicine via What’s App and text messaging. Despite the challenges of resource-constrained conditions, Gipson remains motivated by the impact she has. “You can pay me all the money in the world, but the ‘thank you’ for saving someone’s life is the reward in doing this work.”
he was in end-stage kidney failure, requiring long-term dialysis. With just a few dialysis machines in the whole of Honduras, it was critical that Arita-Bureso remain in the U.S. for his care. To maintain his student visa status, he also needed to stay in school. They were soon informed that his insurance only covered any disease for one year, so that in a few months the dialysis treatment would no longer be paid—a cost of $1,200$1,800 per week. A new kidney would be the best option, and miraculously, Speicher turned out to be a match for his friend. Arita-Bureso had successful transplant surgery just days before the expiration of his insurance. He completed high school and enrolled in college in Houston, but returned to Honduras to visit family. Upon reentry to the U.S., he was told that his student visa needed renewal—an involved process that would take some time, but Arita-Bureso had only a month of extra medication with him. “My congressman helped get him a rush visa interview,” recalls Speicher. “But when they asked Isaias what his plans were after college, he said he wasn’t sure, since his anti-rejection medicine was not available in Honduras. They then denied his student visa.”
A Life-Saving Friendship Twenty years ago, San Antonio ophthalmologist Peter Spiecher (M’82) joined a group of surgeons for an annual medical mission trip in Honduras. While there, he met Isaias Arita-Bureso, a local tour guide, and they began a friendship that would change both lives forever. Speicher sponsored the young man to study in the United States in 2002. But the summer after he arrived, Arita-Bureso began to lose his appetite and he felt run down. Tests revealed
Over several years, Speicher sponsored infrastructure improvements that brought clean drinking water, electricity, and a new bridge to his friend’s Honduran village.
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Speicher flew to Honduras with a three-month supply of medication, and went with Arita-Bureso to his village for the first time. After a three-hour taxi ride to the base of a mountain, they waded through several rivers and climbed up mud roads. When they finally arrived, Speicher was surprised by the living conditions: “They had adobe houses, no electricity, no running water except for a dirty creek. I knew Isaias would not survive for long there with a kidney transplant and his immunosuppression.” Every several months Speicher went to Honduras to deliver the medication. He also sponsored the building of a 50,000 gallon water tank to provide a clean drinking water and a spigot to each home plus three electricity projects completed entirely with local labor. Later, he funded a bridge for one of the river crossings. “Going on a mission trip and doing surgery makes you feel good,” says Speicher, “but a lot of the work that needs to be done is building infrastructure. On medical missions with the Army Reserves, we’d pass out antibiotics, creams for skin rashes, deworming medicine. But if people keep drinking dirty water, they will get worms again the next month. In many cases, it would be better to send the Army Corps of Engineers down there to dig a well or put in electricity.” Over the past decade, Arita-Bureso has continued to face health challenges due to shifting visa approval policies. When he reapplied in April 2018, his visa was denied, says Speicher, out of fear that he wouldn’t return to Honduras. Even with Speicher’s exceptional personal and professional support— immigration navigation, financial help for education and infrastructure, and even a kidney—crossing borders for better health continues to be a struggle.
After residency, she went to Tanzania through the Global Health Service Partnership, a program offered by Seed Global Health, the U.S. Peace Corps, and the President’s Emergency Plan for AIDS Relief (PEPFAR). Launched in 2013, the program builds institutional capacity in global health by placing nurses and physicians in faculty positions at medical and nursing universities, in collaboration with the ministries of health, to work, teach, and train alongside local health care professionals in five African countries. Sustainability was a key factor in McCarty’s decision to join the program. “I knew that if I wanted my interventions to work, I had to be with a program that empowered local staff and students.” In her first year McCarty was the only OB/GYN specialist in rural Sengerema, Tanzania. Her labor and delivery unit saw over 10,000 deliveries annually, and she quickly learned to be innovative in a resource-poor environment. In Sengerema, patients purchased everything from surgical gloves to IV bags out of pocket and brought them to McCarty. Small, private pharmacies nearby supplemented her work; only a few supplies and essential medications were available at her district hospital’s pharmacy. Practicing in this environment forced her to confront difficult questions: “What do you do in these situations when you’re faced with a patient and a diagnosis that you know how to treat, but you don’t have the medication or maybe even the resources to treat it? How do you balance the art of medicine with the science of medicine?” In her second year, McCarty moved to the city of Mwanza to work in an academic capacity at Bugando Medical Center, a
The Art of Medicine Before she had even decided on her specialty, obstetrician and gynecologist Siobhan McCarty (NHS’07, M’11) knew she wanted to work with underserved populations. She grew up near Princeton, New Jersey, and attended an all-girls Catholic school that emphasized community service. Doing advocacy work in Washington, D.C., during her time at the School of Nursing & Health Studies and immersing herself in the School of Medicine’s commitment to service and cura personalis only solidified her values. In the summer following her first year of medical school, McCarty got her first taste of global medicine while shadowing a retired, U.S.-trained family medicine doctor in Johannesburg, South Africa. After that experience, she decided to work abroad. “I knew the direction I wanted to go, so whenever I went for trainings I looked for ways to help underserved communities,” says McCarty. “Having OB/GYN skills allows me to be helpful in many different scenarios.”
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During McCarty’s three years in Tanzania, the obstetrician and gynecologist learned to innovate in resource-poor settings.
referral hospital for the entire Lake Victoria region in Tanzania, and her team handled large caseloads of gynecological and fistula surgeries. Bugando had a 900-bed capacity, but she still operated with resource constraints. “Because I was still in the public sector, not much was different,” says McCarty. “There were more resources in terms of lab tests, diagnostics, and imaging than we had in Sengerema, but we were still using 1990s cooler packs to keep oxytocin and other medications cool.” In her last year with the program, she moved to Hubert Kairuki Memorial University Hospital in Dar es Salaam, Tanzania’s largest city of approximately 5 million. Although they had over 1,000 Tanzanian medical students, McCarty’s OB/GYN department consisted of only three part-time and three full-time faculty, including herself and the dean of the medical school. “That meant large pre-clinical class sizes of 200 and a serious shortage of clinical supervision,” she notes. Despite these challenges and a large caseload of rare procedures and complications like cesarean hysterectomies, McCarty affirms that teaching was one of the most rewarding aspects of her time in Tanzania. “It’s incredibly motivating to be involved with students who are so inquisitive and eager to learn.”
Cura Personalis in Conflict Zones Flying from Miami to Boston to begin his freshman year of high school, Aaron Epstein (MA’12, M’18) was on a plane headed towards New York City as the events of September 11, 2001, unfolded. This led him to pursue national security, studying international policy and economics in college, and working in the defense industry for a few years before completing Georgetown’s security studies master’s program. But he wanted to be more than “just a small cog in the machine.” Working in Lebanon, he saw victims of bombings and shootings. “You would put a tourniquet on someone and that would be a direct, tangible way of helping people. A simple medical intervention seemed more effective at changing hearts and minds than policy work.” So he completed his prerequisites and applied to the School of Medicine. In his first year of medical school, Epstein founded the Global Surgical and Medical Support Group (GSMSG) to provide high-quality medical personnel for humanitarian relief near front-line conflict areas. GSMSG teams offer the full spectrum of care, says Epstein, plus training for local medical professionals to respond to the brain drain often seen in conflict zones. Epstein cites the Jesuit value of cura personalis as a guiding principle for the group. “Georgetown emphasizes that you need to consider the whole patient and their environment,” he says. “So we think about social and cultural factors.” For example, part of the group’s work involves training local women in health care to
Epstein (right) founded the conflict-zone medical relief and training group in his first year of medical school at Georgetown.
increase women’s access to care, particularly in areas where cultural norms limit contact between men and women. GSMSG, which is almost entirely self-funded, has conducted 11 major trips and trained 900 health care providers, including 750 EMT-level medics and 150 physicians and surgeons. The group includes 800 military veterans—former army physician assistants, nurses, or other medical personnel. Although some humanitarian organizations have restrictions around volunteers who are former military members, GSMSG takes the opposite approach. “If you’re going to provide care in a war zone, it makes sense to bring the person who was deployed there for eight years and is comfortable with that operating environment,” Epstein says. And the group is efficient: “For every $50,000 we get in donations, we can do $3 million worth of surgery and training,” Epstein notes, citing minimal overhead. “Our people are volunteering, they have full-time jobs, and every dime goes directly towards the medical effort. Our ultimate aim is self-programmed obsolescence through training locals to become self-sufficient.” Epstein continues to run GSMSG during his surgery residency at the University of Buffalo. The group’s next trip will be to Iraqi Kurdistan, planned for November 2018, and will focus on building up local nurses and staff whose critical work is undervalued, says Epstein. “In the Middle East, many view doctors and surgeons with prestige but equate nursing and therapy with janitorial work,” he says. “We’ve seen the lack of nurses and staff be a huge driver of mortality and morbidity in conflict regions. All the surgery in the world does no good without post-operative or nursing care. The doctors may be good navigators, but if you don’t have people in the engine room, the ship isn’t moving.”
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Welcoming the Stranger For newly arrived refugees in America, taking the entire family to the doctor’s office can be an overwhelming experience. Seattle-based family medicine physician Shoshana Aleinikoff (M’12) is working to make it easier. During her residency in family medicine at Seattle Swedish Cherry Hill Medical Center, Aleinikoff crafted an elective to work on resettlement cases in the Seattle area. Afterwards, she joined the family medicine team at a community health center, HealthPoint Midway, to work with resettled immigrants. Today, her panel consists mostly of newly arrived refugees and asylum seekers, and most are uninsured or rely on Medicaid. As a medical student, Aleinikoff pursued her interest in global health by working on asylum evaluations and affidavits for refugees through Physicians for Human Rights, with Family Medicine Professor Ranit Mishori (M’02). She also completed an elective in Nyarugusu, a refugee camp on the Tanzanian border of the Democratic Republic of the Congo. Meanwhile, her work at Georgetown’s student-run HOYA Clinic allowed her to explore her interest in the longitudinal effects of poverty on health outcomes.
Family medicine physician Aleinikoff (left) facilitates a pregnancy care group for newly-arrived Afghan refugees.
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“HOYA Clinic was one of the most valuable experiences of medical school for me,” Aleinikoff says. “Early clinical involvement—and thinking about the relationships between poverty and health—helped me pursue a residency focused on underserved medicine and helped me develop the tools needed for my current practice.” Originally, she saw people from a wide variety of countries including the Congo, Somalia, Iraq, Afghanistan, Burma, Sudan, and Iran. But recent policy changes on immigration have changed that patient mix, with fewer refugees being admitted and resettled. Today, most of her incoming patients are Afghan immigrants. Aleinikoff strives to build rapport with new families before delving deeper into their medical histories on subsequent visits. “I try to establish myself as the primary care physician for the entire family,” she says. “My only goal for that first visit is to build a welcoming environment that fights the sentiment that refugees and immigrants are not welcomed. If I can build a relationship and get the family to come back, then I think of it as a win. Over time, we can address all of their medical needs.” Otherwise, for many immigrants, the health system may only be accessed in times of acute emergency. With that challenge in mind, Aleinikoff is experimenting with models of primary care for newly arrived refugee families. She hopes that her work adds to growing literature and resources around this type of care. She recently presented to a packed audience at the annual North American Refugee Health Conference and co-published an article with Mishori in American Family Physician. In her refugee care, Aleinikoff sees entire families together, and can capitalize on HealthPoint’s integrated health services: lab work, specialists, dental care, behavioral health support, and nutrition. She partners with resettlement organizations to maximize patient access to care. Often, Aleinikoff must temper recommendations to fit her patients’ circumstances. “Does this make sense culturally, and is it something that can be easily implemented?” she asks. “If a child is anemic, and you make a recommendation to eat iron rich foods, does the family have access to those foods? Is your recommendation consistent with something they would eat based on where they came from or based on their religious allowances?” As the global refugee crisis presses against both the American borders and the American conscience, opportunities to help present themselves in local communities across the country. Global health practitioners are welcoming the stranger and caring for the most vulnerable right here at home, and Aleinikoff believes serving this population’s need for accessible, holistic care can be uniquely met by family physicians. n
When Global Health Is Local From medical evaluations for asylum seekers to primary care for refugees, Georgetown physicians and students work to help D.C.-area migrants.
By Chelsea Burwell (G’16)
woman in her 30s enters an examination room in a Washington, D.C., medical building, a look of quiet determination on her face. Because of the delicate nature and extensiveness of the evaluation, she will be here for three hours. While the duration is lengthy, she doesn’t mind the wait. The goal is to move forward with obtaining asylum in the United States—a process she started months ago. Ranit Mishori (M’02), professor of family medicine and director of the Department of Family Medicine’s Global Health Initiatives at Georgetown, is performing the evaluation. Mishori leads the School of Medicine’s asylum program. Founded in 2014, the program is run by student volunteers who are paired with volunteer clinicians in the Washington, D.C., metro area. To facilitate the asylum application process, the program provides physical and psychological evaluations for asylum seekers. Getting approved for asylum—a legal process undertaken by forced migrants already in the United States—is an intricate and grueling process, sometimes taking years for people who have escaped perilous circumstances in their homeland. “There are a lot of difficult pathways to seeking asylum,” says Megan Pogue (M’21), one of the medical student coordinators of the asylum program. “We are brought in when the lawyers determine that their clients warrant a physical and psychological As a physician and writer with twin careers in family medicine and international journalism, Mishori has a unique perspective on issues involved in global health care delivery.
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The time needed to perform an evaluation and then complete the legal affidavit for these clients is long. It is hard, tedious work.”
Recording Evidence of Abuse
Last year Mishori (in the yellow headscarf) spent time at Cox’s Bazaar in Bangladesh to document medical evidence of trauma among Rohingya refugees. Her experience at refugee sites around the world helps inform her work with asylum seekers in the U.S.
evaluation.” The organization Physicians for Human Rights helps connect asylum seekers with clinicians who are trained to conduct the evaluations. With demand outweighing the number of available clinicians, challenges quickly arise. “A lot of times there are delays in the process, causing a huge backlog of asylum seekers,” Pogue notes. “Many people wait for months and even years just to be evaluated.” The asylum program hosts trainings twice a year for any clinicians interested in helping and performing evaluations. Demand is high for experienced clinicians who can conduct accurate assesments, Mishori says. “It’s hard to recruit clinicians for this work because there’s a specific level of training necessary to carry out the evaluation,” says Mishori. “Some people dedicate time for one evaluation once every few months or whatever works in their schedule.
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Unlike a typical patient visit at a medical office, no clinical care is provided during an asylum seeker’s medical evaluation. It is part of a large process, requires impartiality, and is very technical. Lasting several hours or longer if the client does not speak English, the asylum exams are performed by clinicians who look for signs of trauma—both physical and psychological—that align with the individual’s personal accounts for seeking asylum. This means that asylum seekers must recount their abuse or torture history, along with the sociopolitical conditions that forced them to flee their country. As asylum seekers recall their stories, clinicians like Mishori look for physical or underlying evidence of torture and illtreatment, such as scars, bruises, signs of genital mutilation, broken bones or teeth, and wounds. Pogue reiterates the importance of medical evaluations as a way of improving the chances of asylum approval. “The physical exam is one of the more important aspects because asylum seekers typically have very little evidence outside of their oral accounts. When we can show the trauma of what they’ve been through, it can improve their chances of being awarded asylum,” she explains.
High Demand, Anxiety, and Hope Each year the Georgetown asylum program evaluates a growing number of migrants, totaling 60 since it began in 2014. As thousands of asylum-seekers in the D.C.-metro area await their application review, many still face hurdles as they race to escape life-or-death situations. Shifting immigration policy around deportation creates stress and uncertainty, compounded by alarming stories of family separation and detention. Add in the challenges of learning a new language and culture, and the anxiety felt by many migrants is overwhelming. “People who wouldn’t otherwise want to leave their country, but are forced to leave because of war and persecution, already face trauma,” says Mishori. “Then, the journey to get here is also perilous—from living in refugee camps to crossing borders.
And finally, they arrive and have to battle with acculturation, new climates, a new language, and so much more.” Though there is still much work to be done as thousands await their number in line to be called, Pogue sees a glimmer of hope in the process of helping members of this community. “It’s always rewarding getting the emails from lawyers, saying their client has been approved for asylum after years of waiting,” shares Pogue. “Even for us students, it’s incredible to see, because it shows that human rights has a place in medical education.”
From Forensic Exam to Primary Care Although the asylum program provides one-time, impartial evaluations for asylum seekers, Mishori says that the initiative has expanded to promote continuity of care. The program now offers referrals to primary care physicians and to organizations offering broad support services for survivors of torture. Navigating and maintaining primary care for the migrant community is a feat in itself. While the asylum evaluation process retraces an asylum seeker’s medical and physical health, it is solely for legal and forensic purposes and not intended to treat injuries or medical conditions. Forced migrants seen in the primary care setting may not recognize they suffer from posttraumatic stress disorder, says Mishori, but they show somatic symptoms, such as stomach pains and headaches. PTSD, depression, and anxiety disorders are some of the more common underlying conditions affecting forced migrants.
Culture and Community Prior to embarking on a path in health and medicine, Mishori, who emigrated from Israel to the United States, worked as an international news producer in war-torn countries and conflict zones. Now, as she applies trauma-informed care to her work and advocacy for forced migrants and refugees, Mishori champions the provision of apt and culturally sound medical care for forced migrants, while training other health care providers she encounters to do the same. “Having had the background in the news business, I consider the history of conflicts and issues in countries that many of these patients come from,” Mishori explains. “Putting that together with the patients’ symptoms, physical signs, and potential reasons as to what could have pushed them out of their country gives me a more comprehensive view of their health and well-being.” She adds that the cultural differences between approaches to health—pain management and reliance on medications, confusing medical terminology in a new language, a complex health care system—present a jarring challenge for immigrant patients. With that in mind, Mishori opts for a holistic, cura communitas approach when ascribing primary care to immigrants transitioning into the American fold.
“Individual health is intricately bound with the health of family and community. Everything that happens in the community—your access to food, health, education, employment—affects your well-being, so it can’t just be about the person alone. It has to be about the community and population in which they’re affiliated. “Issues of culture and acculturation are present,” says Mishori. “Regardless of the reason you migrate, it’s not easy to integrate and feel like you’re part of a new society.” Providing evaluations for asylum seekers, and medical care for migrants and refugees, demands something extra from physicans and health workers. They must work to overcome language barriers, bring knowledge of political turmoil or conflict in other part of the worlds, and demonstrate sensitivity to cultural difference. “Often times, the answers lie in the trauma these communities have undergone,” Mishori adds. “To build trust, and more importantly, to build awareness around the circumstance of asylum seekers is vital for physicians and health care providers in this work.” n
Migrants move from one country to another, for any reason, by choice or through force. Forcibly displaced persons have had to flee their homes, due to natural disaster, conflict, or persecution. Refugees are people fleeing conflict or persecution. They are specifically designated, and protected, according to international law as set by the Geneva Convention of 1951. Under current U.S. law, a person must apply for refugee status from outside the U.S. Sometimes large populations of refugees are granted the status as a group, when urgency is required and it’s impractical to conduct individual asylum evaluations. Asylum-seekers are individuals who are seeking international protection and are in the process of applying for official designation as refugees. Often they are already inside the country in which they hope to remain, or they are at a port of entry. Not every asylum-seeker is granted refugee status, but every refugee was at one point an asylum-seeker. Stateless people have no nationality, and thus struggle to access basic human rights.
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ISS U E S I N B I O E T H I C S
Unpacking Medical Tourism
A passport opens up a world of options for those seeking medical care. What are the ethical implications around this burgeoning industry? By Kristina Madarang Stahl
edical tourism occurs when an individual crosses a national border to receive medical services. While the lack of patient data due to health privacy regulations makes sizing the medical tourism industry challenging, some estimates place the global value at over $70 billion. Though many of today’s medical tourists travel for plastic surgery and dental procedures, a study by PricewaterhouseCoopers projects that pricier, riskier, and more invasive procedures such as cardiac and orthopedic surgery will grow in popularity and double the value of the medical tourism industry. The Medical Tourism Association cites major price differences internationally for procedures like liposuction and knee replacement. For example, a heart bypass in the United States costs approximately $123,000 compared to $14,000 in Poland or $7,900 in India.
Top specialties for medical tourism are dentistry, cosmetic surgery, and reproductive care, and popular destinations for procedures span the globe, from Thailand to Hungary to Costa Rica. The burgeoning trade raises numerous ethical concerns for patients, practitioners, and policymakers. “First and foremost, what is the reason for your travel?” asks California neurologist Michael McQuillen (C’53, M’57, R’60). “Is it to obtain a treatment not available near your home? If that is so, why is it so? Is it too expensive at home, or is the waiting time for the treatment unreasonably long? Is it ethical to prolong waiting times for residents of your destination by entering what is (or should be) essentially their waiting line for those services?” Patients often become medical tourists due to prohibitive costs or poor quality of care in their home country. With its
reputation for low costs, high standards of care, and use of cutting-edge medical technologies, Asia has historically been the prime destination for such tourists, especially for cosmetic surgery procedures, now closely followed by the United Arab Emirates and Greece. Perhaps by accident, America has stepped into the ring, with a controversial example being the wave of Chinese women participating in birth tourism in Saipan to gain American citizenship for their children. To address some of these issues, we contacted Georgetown’s Pellegrino Center for Clinical Bioethics and spoke with James Giordano, PhD, who leads the neuroethics studies program.
What is your forecast for medical tourism? Without doubt, medical tourism— and research tourism—will increase during the coming decades, as biomedical science and technological enterprises become ever more multinational, and the relative parameters and policies regulating practices in different countries become more varied. This might encourage vigorous discussion and pursuit of guidelines that ensure patient safety and continuity of sound patient care in and between nations. Guidelines may establish minimum criteria for research efforts, and address the translation of research findings, tools, and methods to clinical care. Not a simple task, but it is important and necessary.
What’s your advice for the prospective medical tourist? Seek assurances regarding the safety of any procedure. Has the technique been
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New Program in Catholic Clinical Ethics
evaluated and demonstrated for safety and effectiveness in clinical use? What personnel resources and services are available during preparation, articulation, and recovery? Also, find out if care for any latent effects incurred by techniques administered outside of the United States would be treatable, and covered by insurance once the patient returns here. This is of particular concern if such techniques are not approved in the U.S., or if they or the follow-up care do not fall under an existing or accepted procedure code.
How is Georgetown involved in the medical tourism ethics arena? Our responsibilities are threefold. First is the need to remain apace with developments in international biomedical research and its translation into medical practices that are viable and valuable for generating and sustaining research tourism and medical tourism. Georgetown’s ongoing educational and research projects in international health and clinical and translational science are notable in their efforts to this regard. Second, it is important to know what types of medical treatments are being offered to medical tourists and what the manifest effects of such treatments might be. This knowledge helps to establish medical readiness for conditions that may be encountered in patients returning from treatments in other countries. Finally, Georgetown is engaging in proactive discourse in international forums to address the scope and conduct of research and medical practices, with an aim to develop ethical guidelines and policies that will be important for safety and patient health. n
n online master’s degree designed to help the next generation of health care providers and administrators understand the ethics and moral theology that guide Catholic health systems will be offered beginning this fall. Georgetown University Medical Center (GUMC) partnered with the Catholic University of America with support from the Catholic Health Association of the United States (CHA) to create a Master of Arts as well as certificate programs in Catholic Clinical Ethics. Individuals trained in ethical reasoning have long provided leadership and guidance at Catholic hospitals, but more is needed in today’s quickly changing world of medicine, says G. Kevin Donovan, MD, director of GUMC’s Pellegrino Center for Clinical Bioethics. “Fundamental questions are being raised by rapid technological breakthroughs, limited resources, and shifting social trends,” Donovan says. “These include questions that range from the provision of high-quality health care for everyone, especially the poor and vulnerable, to how clinical advances in genetics and neuroscience change what it is to be a human person.” The new programs will draw on the institution’s expertise in medicine and bioethics to teach current and future health care professionals about that unique perspective. CHA notes that one in six patients in America is treated in a Catholic hospital. As a pre-eminent Catholic and Jesuit university with a medical research and education campus, Georgetown is well-positioned to offer the programs, Donovan says. “There are plenty of master’s programs in bioethics at universities around the country, but they are not strongly
oriented to a clinical perspective, and few are rooted in Catholic moral theology,” Donovan explains. “That makes these programs, both the certificate and master’s degree, unique. They are designed to guide the provision of medical care that has social, pastoral, and spiritual responsibility.” The programs are being offered entirely online so that a national pool of candidates can apply, with many candidates expected initially to come from Catholic Health Association institutions. The teaching faculty for the programs will include physicians, researchers, ethicists, and clergy from Georgetown and Catholic University. The curriculum covers a wide range of subjects, including medical care vs. health care; end of life ethics; research ethics; pain/palliative care; sexual, reproductive, and gender ethics; health care reform; justice and health; clinical ethics and the law; and neuroethics. “We are considering big issues—the nature of life itself, human dignity, health equity, the common good, and highquality care for everyone,” Donovan adds. “Our goal is to provide the kind of health care that everyone would want.” n
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ON C A M P U S
Technology Catching Up With Sci-Fi Georgetown invention offers speedy genetic detection of bacterial and viral pathogens By Monica Javidnia
ountless science fiction movies and crime dramas share one thing in common: the presence of technology guaranteed to frustrate anyone with a background in the life sciences. A laboratory technician sequences a genome in a matter of seconds while tablets quickly display diagnostics on humans, robots, and everything in between. Admittedly, I am guilty of shouting in the theater, “It doesn’t work that way!” much to the annoyance of my fellow moviegoers. But research led by investigators at Georgetown University Medical Center is turning fantasy into reality. “We have developed a technique that can rapidly detect specific genomic DNA,” explains Mark Danielsen, PhD, associate professor in the Department of Biochemistry and Molecular & Cellular Biology. The invention, known as Fluorescence Activated Sensing Technology (FAST), could have major implications for disease diagnosis in remote locations, surveillance of water supplies and agriculture, environmental monitoring—the possibilities are endless. The process is simple, quick, specific, and does not involve the use of the slower PCR method (polymerase chain reaction). From the Greek poly “many” and meros “part,” PCR is a widely used technique in biological research developed in the 1980s through which sequences of DNA are identified and replicated multiple times. This process can be costly and time-consuming, requiring numerous chemicals and specific equipment, and may result in false positives or negatives. The new FAST method, protected by two issued patents and a third awaiting issuance, is a vast improvement from the status quo. Along with Danielsen, other
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inventors are emeritus faculty Eugene Davidson, PhD and Kenneth L. Dretchen, PhD. The work was developed in the early 2000s for a multimillion-dollar project sponsored by the Department of Defense to design an instrument that could detect biological threats. Research and development from Danielsen and colleagues resulted in detection probes for Bacillus anthracis and Yersinia pestis, more commonly known as anthrax and the plague, in addition to a detection device for use with the anthrax probe. The probes are customizable and can detect specific targets in blood, urine, the environment, and other sources, making the technology highly versatile. The success of this technology high-
lights the importance of interdepartmental collaboration—namely between the Department of Pharmacology & Physiology and the Department of Biochemistry and Molecular & Cellular Biology —as well as institutional support. In addition to helping with patents and material transfer agreements, Georgetown’s Office of Technology Commercialization (OTC) works to ensure that Georgetown inventions are used for the greater good, and helps found and develop local businesses. The OTC played a pivotal role in the patenting of the FAST technique and its progression by helping to secure additional research funding. An outside consultant engaged by the OTC described the promising technology as a “diamond in the rough,” notes Claudia
O’Donnell Named Cohen Chair Steward, PhD, vice president for technology and commercialization at Georgetown. The inventors continue to explore applications for the versatile FAST method. They used it to develop a new chlamydia probe, for example, allowing for rapid, low-cost diagnosis and ensuring people are getting the appropriate treatment. This is particularly important as chlamydia is often asymptomatic, and if symptoms are present, they may be similar to those of other diseases. Most recently, the technique has been improved for use as an array technology, with the potential to screen hundreds of organisms at the same time within a single sample. So, the next time we are sitting in a theater, hearing the buzzes and whirrs accompany flashing lights from a seemingly fantastical diagnostic device, instead of groaning in disbelief, perhaps we can smile knowing the technology is coming to fruition. n Monica Javidnia is an amateur homesteader in Upstate New York, and a postdoctoral fellow in regulatory science and experimental therapeutics in the department of pharmacology and physiology at Georgetown University, and the University of Rochester’s Center for Health and Technology.
nne E. O’Donnell (M’82, R’85, W’87), professor of medicine and chief of the division of pulmonary, critical care and sleep medicine at MedStar Georgetown University Hospital, has been tapped as the Nehemiah and Naomi Cohen Chair in Pulmonary Disease Research. Having authored over 40 manuscripts, O’Donnell is an internationally recognized expert in bronchiectasis and respiratory infections. She has been a principal investigator on numerous clinical trials investigating therapies for bronchiectasis and nontuberculous mycobacteria infections. O’Donnell’s distinguished career makes her the “natural inheritor” of the prestigious Cohen Chair, according to her colleague Richard Waldhorn, MD. “Anne has applied the principles and values by which she has lived her entire life. First, work hard. Then become an expert, and learn all that you can possibly learn. Next, always respect and listen to the patients—by taking a careful history without the assumption that someone else has asked the important questions. And most importantly, strive to understand the patient’s perspective.” Endowed chairs are one of the highest honors awarded to faculty. The Cohen Chair has engaged world-renowned
physician scientists in the research and academic mission of Georgetown and has sustained scholarship over decades in the area of pulmonary disease research. It was established in 1986 by the children of Nehemiah and Naomi Cohen. The inaugural Cohen Chair was awarded to Sol Katz, MD (M’39), who held it while a national search committee was underway to find a permanent chairholder. Katz was followed by Donald Massaro, MD, who was appointed in 1987 and served as the chair until his death in 2014. “Having this chair makes an important contribution to moving forward in these very rare diseases—they’ve been understudied, under-researched, underfunded,” O’Donnell says. “I hope that with this chair, we’re going to make good contributions to the care of the patients.” n
“At Georgetown we recall the words of our beloved Proctor Harvey, who reminded us constantly of our G.T. Ratio —our give over our take. It should always be greater than one.” – Donald Knowlan, MD, professor emeritus, speaking to incoming medical students at the 2018 White Coat Ceremony
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ON C A M P U S
After Trauma, Hope
n a time when secondhand suffering as a caregiver can lead to vicarious trauma, Hope Ferdowsian, MD, MPH, adjunct associate professor of microbiology and immunology at the School of Medicine, wants to reframe perspectives. By studying the science of surviving and thriving despite trauma, she says, not only can people experience vicarious resilience, but they can also steward societal progress. Ferdowsian’s book, Phoenix Zones: Where Strength Is Born and Resilience Lives, explores places that foster the recovery of human and nonhuman animals who have lived through unimaginable physical, psychological, and emotional pain. These healing sanctuaries or “phoenix zones” are cultivated across the world, such as the Global Sanctuary for Elephants in Brazil, the Warrior and Wolves project in Los Padres National Forest, California, Sisu Youth homeless shelter in Oklahoma, and Farm Sanctuary in upstate New
G E O RG E TOW N MEDICINE
York. Ferdowsian profiles each place through narratives of individuals affected by the sanctuaries, and binds the phoenix zones together with a common set of foundational principles: respect for liberty and sovereignty, commitment to love and tolerance, promotion of justice, and the fundamental belief that each individual possesses dignity. The people and animals that Ferdowsian met on her worldwide travels as an advocate inspired this book, but one key idea coalesced during Ferdowsian’s work on the Hilltop: as a physician evaluating the visible and invisible scars of asylum seekers and refugees, Ferdowsian says she has come to see the principles at the heart of Georgetown’s mission—freedom, compassion, and justice—as biological needs that humans share neurologically with other animals. When humans witness or assist the fulfillment of these needs, through acts of kindness and justice, the reward and pleasure areas of our brains activate,
making future acts of kindness and justice more likely. “Kindness and justice can be contagious,” she says. The book is a resource for people who wish to learn about the structural ties between violence against animals and human beings, and how to foster more interconnected healing across species and communities. Caring for survivors of trauma can help break the cycle of violence, trauma, and suffering, Ferdowsian says. “By learning from the experiences of survivors, we can all become more resilient and compassionate.” n — Kate Colwell
World of Choices In September, generations of Med Hoyas connected in person at the World of Choices event to discuss career steps such as residency, training, education, and research. Nearly 50 medical students and 20 medical alumni from different specialties attended the program, organized by GUMC Engagement & Annual Giving. While this event last occurred in 2015, plans are to convene on an annual basis going forward. n
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AL U M N I C O N N E C T I O N S
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What’s in my white coat? Fernando Pagan (M’96, R’00) is a movement disorders neurologist at MedStar Georgetown University Hospital. He is a professor of neurology, director of the movement disorders program, and medical director of the hospital’s National Parkinsonism Foundation Center of Excellence. 1. I carry the penlight to look at the pupillary reflexes and the back of the throat. 2. Neurologists check reflexes and motor restraint, and conduct sensory testing. The tuning fork helps us assess hearing but also the vibration sense in the feet and hands, and because it’s metal we use it to test for cold sensation. 3. I break wooden stick swabs in half and use one end for pinprick sensations and one for soft sensations on hands and feet. 4. Stethoscope—I’m on my third or fourth one by now. 5. Patients often ask for my card. 6. Sometimes I use my iPhone to check vestibular ocular reflexes using optokinetic tests. In the old days I kept a striped paper strip to move in front of the patient’s eyes. 7. I carry pens because we still use paper charts in research. 8. My reflex hammer is the same one I got as a third-year medical student.
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I had planned to be a pediatrician, but with the influence of my psychiatrist father, plus the dopamine and spinal cord research I did before and during medical school, my eyes were opened to neurology. I did enjoy pediatrics but I enjoyed the neurosciences even more. I did the next best thing—I married a pediatrician (who is also a Georgetown alum). I love being part of Georgetown. I’ve been here throughout my training and I’m able to pass along my knowledge to medical students, residents, and now fellows. So far we’ve trained 27 fellows in a field that is underrepresented in neurology: movement disorders. When I began I was the only movement disorders specialist at Georgetown, but now we are a team of nine. We’ve built a regional translational neurotherapeutics program and we opened up a new area of research in neurodegenerative disorders, not only in Parkinson’s Disease but also Alzheimer’s, Huntington’s, Lewy body disease, and possibly ALS. n
Giving Back, Together
hen Daphne Keshishian (M’93) graduated from the School of Medicine and went on to complete her residency in New York and then in Arizona, Georgetown came with her. “No matter where I was, I felt such a strong Georgetown presence in the alumni networks,” she recalls. “That impressed me and I felt grateful for my education because Georgetown alumni were respected everywhere.” When she moved back to the Washington, D.C. area where she currently practices, she reconnected with alumni, served as a mentor to medical students, and started to think
about new ways to give back to the School of Medicine. This included giving back financially through the School of Medicine Scholarship Fund. “The cost of medical school is tremendous. As alumni, it’s important to do whatever we can to help alleviate the financial burden that comes with the commitment to medicine,” she says. “Sometimes people think if they can’t write a large check, it’s hard to make an impact. But when we all come together, we can help defray the costs of medical school for future Georgetown students.” Keshishian now serves on the Medical Alumni Board, and is ambassador for the Class of 1993. As her 25th reunion
approaches in October, she is working with classmates to create an endowed scholarship. “Our 25th reunion is an opportunity to unite our class to make a gift to future Georgetown medical students—a gift that will literally keep on giving,” she says. “It’s so rewarding, and it’s a great way for our class to leave a legacy. We are more powerful together than we are apart.” n — Leigh Ann Sham
Visit giving.georgetown.edu to learn more.
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Reflections on medicine with
Ayaz Virji (C’96, M’00)
I’m Indian ethnically, born in Kenya. I grew up in Florida, with very little diversity. When I was a kid my OB/GYN uncle would take us to the hospital doctors’ lounge for free ice cream and I thought, “I want in on this!” I am Muslim and went to mosques in my childhood. I never understood Islam until I learned it from the Jesuits at Georgetown. Family medicine’s biopsychosocial model—care beyond the physical entity that takes into consideration the economical, biological, spiritual, and emotional—resonated with my approach to life. In medical school our attendings impressed on us that we are stewards of knowledge—we don’t own it. The person who gives us the honor of learning from them as students, or practicing on them, or cutting them up in gross anatomy, does it for the benefit of humankind. As a resident I saw my first pediatric case of diabetes and it broke my heart. I saw that lifestyle changes were important but our profession had not emphasized them yet. Since coming to Dawson
I’ve helped residents lose 3500 pounds. They’re healthier, and need less medication. In big health systems, care becomes fragmented to accommodate
volume, and primary care is almost a triage scenario where patients come mostly for referrals to specialists or for imaging.
In rural medicine we work at the height of our training. In Dawson we have a clinic, a hospital, an ER, a nursing home— I do it all. I do my own intubations. Specialists come just once or twice a month. If someone has abdominal pain, I get the scan and lab results. If there is appendicitis I admit that patient, call the surgeon, follow the patient in the hospital, and see the patient when they come out. I know their values. They know and trust me.
The hours are long. This is the hardest I’ve ever had to work in my life. Good primary care is a solution to our current health care crises around affordability and sustainability. We have tremendous potential to reduce costs and improve care. We’re idealistic when we go into medicine: “I don’t need money, I’m just going to live on a farm and take care of people.” Then you have a family and bills and you have to balance those ideals, but I make time to work at free clinics. I learned this from family physician Dr. Robert Cutillo at Georgetown. Finding the balance to serve humanity, beyond just making a profession, makes life meaningful and gives us peace. What I love most about my work is the patients. I need them as much as they need me. I feel such a sense of satisfaction taking care of them, when they smile, lose weight, lower their blood pressure, come off medications.
Keeping up with the latest in medicine is a moral act. Physical activity has been designed out of our environment. I invented BodyTogs, anatomically designed wearable weights. When you wear them all day, they equate to a two-mile run in terms of calorie burn. In medicine, the science alone is challenging, but we can also get lost in the complexity of the administration of health care. As clinicians we can find ways to solve those problems. We shouldn’t lose hope. I’ve had doctors tell me they can’t continue in the system or they wish they’d never become a doctor. It’s sad to hear, and the despair is infectiously disheartening. They’re forgetting what this is about in the first place: the doctor and the patient. That’s sacred. n
In 2014, this family medicine doctor took a leap of faith, leaving a big practice in Pennsylvania and moving with his wife and children to Dawson, Minnesota, population 1500, to practice rural medicine. They felt welcomed, but were disheartened after the 2016 presidential election when nearly half the town voted for a proponent of anti-Muslim rhetoric. At the urging of a local Lutheran pastor, Virji added public speaking to his repertoire, and began the “Love Thy Neighbor” series to promote religious understanding and interfaith dialogue. His book about the experience comes out in 2019.
inspired to give Growing up in Washington, D.C. and working in public health, Jacques Carter (M’79) has always felt strongly about giving back. “My involvement as both a donor and a member of the Georgetown University African-American Advisory Board is something I take pride in. As part of my philanthropic legacy, I encourage medical students who are beginning their professional careers to get involved and stay involved in their communities in any way they can, offering time, talent, and treasure. Georgetown has been an instrumental part of my success as a professional, and supporting an institution that has supported me is paramount.” J. Jacques Carter, MD, MPH Assistant Professor of Medicine, Harvard Medical School Beth Israel Deaconess Medical Center
Join Dr. Carter in supporting Georgetown. For information about giving or ways to get involved with the School of Medicine, call 202-687-6673 or email email@example.com.
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Gaston Hall glows with promise at the White Coat Ceremony in August, as Professor Emeritus Donald Knowlan, MD, leads the incoming class of medical students in the Hippocratic Oath.