Tuesday, March 17, 2015

Being Mindful of Global Health

By Usnish Majumdar

I have no fear of making changes, destroying the image, etc., because the painting has a life of its own.

When I try to imagine global health, I think of a vast and complicated network of people, institutions, and rhetoric. There are these huge hubs like the UN Refugee Agency, the World Health Organization, and Partners in Health, and there are the smaller hubs of academic medical centers and national advocacy groups, and then the tiny little pinpricks made up of student groups and incipient organizations. They all serve individuals in different ways and at different levels, adding to their perceived complexity. In my head, it all ends up looking a bit like the wiring of a brain. But it’s probably quite a bit more like a Jackson Pollock painting. 

This sort of hand-wavy network metaphor is one of many that exist in the rhetorical space of global health. In many cases, such networks are little more than words that pass with conversation, or transient constructs built for the sake of argument in a paper. In other cases, however, a network manifests as an institution (really, a hub) that often focuses on one particular interest or another. These institutions are serving an important goal: making the network more effective and efficient. We can see the benefits of bettering networks in many contexts – NGOs all over the world are solving similar problems but there is no easy way of exchanging relevant institutional knowledge. Even within a single city, it is sometimes difficult to figure out which entities (policy briefs tend to call them ‘stakeholders’) are impacting a problem in which ways. Many local networks contain redundant members or potential collaborators that are not aware of each other.

At UVA, global health takes many forms. There are over a hundred different student groups devoted to a global health-related goal on grounds, and no real organizing principles. There are research groups across many different academic departments, not to mention multiple administrative centers that reach across multiple departments. Multiple national advocacy groups have student members on grounds. Occasionally you’ll come across a group’s educational or awareness campaign in one of numerous global-health related courses offered each semester. There are physicians and epidemiologists working as part of the hospital system that team up with students from multiple schools.

This glorious mess is part of why I love UVA, but the network is plagued with many of the same inefficiencies that we see elsewhere. Even a cursory search reveals redundant student groups. Students that decide to engage with global health are faced with decisional overload – there are so many different ways of getting involved, some of which are far more visible than others. People working in a particular region will hear “through the grapevine” of other UVA projects in the same region, often after having done a lot of groundwork without knowing of potential collaborators. Research collaborations in global health are necessarily transient and spontaneous, but there are few structures that make this more likely at UVA. 

Over the past few months, the Student Advisory Board has been working to build an interactive, sortable network of all the Global Health entities around grounds. We hope to have it done by the end of the semester, but mapping everything out visually is only the first step. A network map is a tool, not an end. With some effort on all fronts, perhaps we can make a Jackson Pollock painting look a bit more like a brain.

To be continued...

Saturday, November 8, 2014

Diabetes, Chili Beans, and A1C's: Project HOPE in Action

The A1C, or HbA1c, is a common test for diabetes that measures levels of glycated hemoglobin in an individual's blood stream.  When diabetes is not controlled, sugar buildup in up in blood is detected as sugars are glycated, or bound, with hemoglobin.

A chili cook-off in central Virginia might be the last place one would expect to find a group of medical students with handheld A1C machines.  But among the steaming pots of chili - where tasters wore camouflage coats and a guitarist covered hits of The Band and Bob Marley - citizens of Louisa, VA checked their blood sugar.

On Saturday November, 1st, patrons of the Earlyhouse 10th Annual Charity Chili cook-off also checked their blood pressure, discussed healthy food options with a dietician, and checked their kidney function.  It was overcast and windy, a perfect day for chili but also an ideal day for Project HOPE to do what it does best: interact with the local community and promote health through disease screening.

Wednesday, October 8, 2014

Ebola Panel: Action Now and in the Future

On her way out of the medical auditorium, Dr. Christiana Hena taught us the Liberian handshake. As you pull your hand away, you snap your finger against the other persons. But now in Liberia, people don’t shake hands like that anymore. They give each other a thumbs up. The reason: Ebola.

Today’s panel discussion allowed us a more intimate understanding of the effects the viral epidemic has inflicted upon West Africa over the course of a few short months, beyond the commonly cited numbers in the media. The loss of intimacy in everyday life cannot be as easily quantified as mortality statistics.

As Dr. Hena and the other panelists spoke (virologists, a WHO consultant and two anthropologists), they opened up how the epidemic is not merely an isolated outbreak. It has roots not only in the civil war that devastated the nation over a decade ago, destroying 242 of the 290 health centers, but also in the policies that have resulted in the inadequate restoration.

The problem has not been lack of international investment in health in Liberia, Sierra Leone and Guinea, explained anthropologist Dr. China Scherz. Rather, money poured into projects and vertical pharmaceuticals, instead of building basic infrastructure and education, has not lead to sustainable solutions.

In the region where Dr. Hena works, for example, there were only three physicians for 200,000 people at the time the epidemic began. In July, clinics were closed, and nurses took it upon themselves to care for patients. Thirteen without access to proper PPE equipment died.

Meanwhile, ex-patriots and NGOs fled. While no one could fault them as individuals, the gaps they left at all levels of basic service delivery show the problems in failing to train capable local individuals.
At the moment, resources must be aimed to contain the unimaginable disaster and develop therapies. Drs. Frederick Hayden and Judith White explored the current therapeutic and prophylactic options under development, explaining the molecular basis for the Zmapp, siRNAs and experimental vaccines under development.

The panel left me reflecting on the conditions that allowed the Ebola epidemic to develop. As Dr. Christina Hena said, the national and international organizations should have known this would happen in a country with fragile health infrastructure. In March, when the first cases were reported, nobody did anything. March went by. Then April, and nobody did anything, except Ebola songs (http://www.youtube.com/watch?v=1_WOR22-SnY ) started coming out and people danced to them. Because they didn’t know what Ebola was, so they danced to the music.

Given the delayed response, absence of health care and witnessing horrific consequences of the disease, it is hardly surprising that the public do not trust those who come in the “space suits” to provide them aid. Rather than blaming people for eating bush meat or their funeral practices, perhaps the better question is what public health practices have led people to not trust those who come to help at this late hour.

I cannot help to think what the implications will be even in the best-case scenario. The few hospitals there are empty, many health workers have died, schools are out and the social fabric made up of handshakes, hugs and family closeness have dissolved. Chronic health conditions and mental health sequela of the epidemic are unlikely to be resolved in the short-term. These all lead us to question how public health is carried out and how such enormous disasters may be prevented.

For now though, the escalating emergency calls for the investment of health care resources. During the session, the question was posed as to when UVA can return to West Africa. Pethreree Norman, a Liberian nurse and student here at UVA, had a response. UVA does not have to leave West Africa, but can participate in the efforts through fundraising. She has already collected 1705 dollars and 2000 units of medical supplies to send to Liberia. Your donation will help alleviate shipping costs to the organization Aid for Ebola Liberia.

You can contribute at: http://www.gofundme.com/dm8ybk Now is the time to stop this epidemic from devastating the lives of the thousands it continues to kill, 40% of which have died in the last 21 days.

But at the same time as we contribute in solidarity, the panelists urge us not forget about Liberia, Sierra Leone and Guinea once Ebola is out of the news. The solutions of empowerment and capacity building they offered are relevant in all of global health. If we do not want a next disaster, we need to fix the way we do public health.

Monday, March 3, 2014

Report and Reflection: The 2nd UVa Global Health Case Competition

“5:30am,” replied the bleary eyed student.

It was Saturday morning and I had just asked her what time she had gone to bed the previous night. No, she hadn’t been partying it up on the corner—she and her interdisciplinary team had been polishing up their presentation for the second UVA Global Health Case Competition. The first iteration of this event in 2013 had challenged participants to present proposals to control the menace of extremely-drug-resistant tuberculosis and other health concerns in the slums of Mumbai, India. This year’s case was equally challenging: prioritize the health needs of Syrian refugees and develop a pilot program to address these needs in Syria’s neighboring countries.
Case Competition Flyer (courtesy: Manya Cherabuddi)
The case, written by a group of students from across the University and including members of last year’s winning team, objectively described several problems and complicating factors that the United Nations High Commissioner for Refugees is currently facing. About six million Syrians are internally displaced and another 2.5 million have been scattered across the middle-east and Europe as a result of the crisis, which many believe to be the most serious humanitarian crisis since the Rwandan genocide of 1994-1995. Syria’s health infrastructure has been reduced to rubble by the conflict, leaving Syrians with no preventative health services. Consequently, the recurrence of polio was unsurprising, but horrifying for a global community that has invested some much to eradicate this disease.

The case also focused significantly on social and health issues plaguing the women among the Syrian refugees. Not only are there insufficient obstetric and gynaecological services available to Syrian women in the refugee camps, they are also forced into an oppressive social dynamic. For instance, young Syrian girls are coerced to marry older local males in hopes of establishing economic security for their families. The danger of rape and molestation is ever-present in the tumult of large refugee camps. The case cited the example of women in the Za’atari camp who actually dehydrate themselves during the day to minimize toilet use as they fear lurking rapists. The case challenged students to propose a realistic initiative with a maximum budget of $25 million to ameliorate one or more identified issues in Syrian refugee populations.

One of the finalists explaining their vision
The students were given the case on Monday and had until Saturday morning to formulate their proposals. Some of the teams were pre-made and others were randomly created with students who had applied to participate in the competitions individually. All in all, we had fourteen teams with representatives from at least three different disciplines. Within a week, they researched the situation, identified the issues they were going to tackle, and designed an innovative intervention. From my participation in the 2012 Emory Global Health Case Competition in Atlanta, I know the incredibly hard work required to produce a presentable solution. My team members and I easily spent more than 30 hours individually to develop an appropriate health intervention for Sri Lanka. I saw teams put in equally hectic hours for our internal competition this year.

The product of their labours was commensurately incredible. I really enjoyed the detailed and diverse proposals on display. The proposed interventions ranged from cash transfers and social entrepreneurship grants in Lebanon to enhancing the educational facilities in Jordan. The winning team, Healthy Hoo’s, had students from the Frank Batten School of Leadership and Public Policy, the Curry School of Education, and the College and Graduate school of arts and sciences. They were notable for the wonderful way in which they interwove their innovative proposals with the narratives of individual Syrian refugees, reminding us of the mass of humanity at the root of this situation. The runners up, Power Rangers, were a team of RAs, who were impressive in the focus and detail of their proposed GIS surveillance system.

Our wonderful judges
Obviously, I didn’t engage with the case with anything close to the intensity that the teams displayed. However, I think I learned an important lesson from our incredible case writing team and dedicated contestants. A common and powerful theme in all the presentations was the importance of providing normalcy to the refugees. Medical education instils a strong predilection for pragmatism into students like me. This leads us to focus on things like diarrhea, obstetric complications, and vaccinations. The importance and cost-efficacy of interventions like these are above questions, but are they enough?

Before medical school, I fancied myself to be a biologist and often had to consider whether an element in a given molecular process was necessary, sufficient, or both. In this case, I believe that our pragmatic medical priorities are necessary, but not sufficient. Refugees are not just broken bodies to be fixed and mouths to be fed. They include children who dream of becoming astronauts, teachers with a passion to inspire generations, and carpenters who take pride in things they construct with their hands. Often-times we forget this and, years after their formation, refugee camps continue functioning in an emergency-mode, putting bandages on wounds but not charting a path back to normal life.

At the 2014 UVa Global Health Case Competition I realized that working with (and I mean WITH) the refugees to construct channels back to a productive and vibrant life, in which they can heal from the scars of conflict, is as legitimate a priority as giving them clean water and food.

Tuesday, November 12, 2013

The [Uganda] Motorcycle Diaries

On the road. The problem…the solution?

In a packed room of students and professors, Dr. Charles Muchunguzi spoke on his work with motorcycle ambulances in Uganda. The project, funded by UNICEF, aimed to decrease high maternal and child mortality by facilitating access to local health centers. Motorcycle ambulances would be a sustainable and efficient solution to target transportation issues in hilly, poorly kept roads. They would transport pregnant women to the closest health care center, mostly for the actual birth, as well as others in case of medical emergency.

Traditional ambulance maintenance costs, breakdowns and incompatibility with poor road networks had led to misuse or nonuse in poor communities. In addition, the motorcycle intervention had proved very successful in other countries like India, as well as in eastern Uganda.

Despite promising prospects on paper, development expansion is not simple. In the two districts of western Uganda (Mbarara and Bushenyi), the pilot project largely failed: the pregnant women did not use the ambulance. In the better-off Mbarara district, only two women used it during a nine month period. In Bushenyi, the communities showed mixed feelings about the ambulances; yet, without access to alternative transportation, they did use it more.

Riding in the “ambulance” felt anything but safe or reassuring to the women. If they had used it, they would have lain in the back on a thin mattress across a hard surface. The carriage of the ambulance would shuffle from side to side across the turns, giving the sense that they would soon topple over. Indeed, the very community health workerswho were asked to promote the intervention had experienced an accident in the vehicle.

The women, instead, chose to walk, ride a boda boda  (normal motorcycle) or give birth at home just as they had done before the project.

Encounter with the ubiquitous roadblocks (not just metaphorically)

Dr. Muchunguzi´s presentation gave the viewers a touching, if brief, encounter with doing interventions on the ground. I cannot say how refreshing it was to hear such a thoughtful, critical and honest presentation. It has not been often that I have met someone so willing to expose the difficulties with a project that meant so much to them. I felt truly honored to hear him speak.

For me, his presentation had meaning far beyond the individual project. It showed how projects set up by well-meaning organizations often do not work: he mentioned latrines (built by the work bank but not used because of community taboos against mixing feces of the young and the old) and bed nets (used for wedding dresses and fishing nets)

Many of my friends and colleagues who have done international work have come back with the same sense of frustration: many interventions are done for communities with little real impact in the long term.

Witnessing this frustration over and over can burn out the very people who wish to affect change.  How could such an elegant idea as a motorcycle ambulance, which worked in so many other places, fail?

Rather than being frustrated, Dr.Muchunguzi provided insight into how modifications might be made in order to make the solution work. UNICEF is currently working on redesigning the motorcycle ambulance; other ideas were provided by the community focus groups post-intervention, such as making four wheel ambulances (“does that then become a car?”) or subsidizing local cars. Also, communities that had already organized and funded the infrastructure for the project (a shed to put the motorcycle in, compensation for the driver), had much higher acceptability.


Motorcycles can be an elegant solution to an important problem, but only if people will use them. Asking them if they want what you have is not good enough. As Dr. Muchungunzi said, people are not stupid; they know what the developer wants and, with money riding in the balance, they will give it to you. Even flimsy motorcycle ambulances for free are better than nothing. Just as we might take a free pen because it is there, it does not mean we will continue to write with it if the ink is constantly drying up. Community buy-in to the purpose of the intervention and real contribution to the design of projects cannot be seen as ancillary to their success.

In the villages where desire for motorcycle ambulances existed prior to the project, the intervention worked much better. Community buy-in can be sought through active consultation in focus groups throughout a project, as well as incorporating appropriate and respectful care. For example, It is possible to incorporate cultural practices like vertical birth in clinical settings.

Moreover, a single intervention cannot stand alone. It is only a solution if the health care encountered in the health post is of high quality and will really improve maternal mortality. It is only a solution if the roads are good enough for the motorcycle ambulances to get to people’s houses.

His talk, to me, highlighted the importance of quality in planning interventions, quality in community buy-in and engagement in the project and quality in the services that are provided to people. While asking pregnant women to lie on thin, hard mattresses in precarious vehicles might be deemed cost efficient and sustainable, such a service may fail to respect their human dignity.. Rather than accept this loss of dignity, many continueto give birth in solitude or solidarity.

We would like to thank Dr. Muchunguzi for his presentation to the UVA CGH and IMS, as well as Dr. Kabachenga for his support of the motorcycle ambulance intervention research.

Monday, October 21, 2013

Opening Reception of "GUZIKA (to heal):The Art of Rwandan Children" Exhibit

Everyone had gathered around to watch the pair of young women dancers. As they hooked and whirled like spinning tops on the art gallery-turned-dancefloor, their bright geometric dresses seemed to take on a life on their own. Periodically wiping sweat from their brows, several drummers seemed determined to compete with the dancers’ liveliness. The young women began dragging reluctant audience members onto the floor with them, and soon several dozen children and adults were bouncing to the drumbeat.
The band, CHIHAMBA, was there to kick off the opening of GUZIKA (to heal):The Art of Rwandan Children Exhibit at the McGuffey Art Center in downtown Charlottesville. It was one several exhibits of artwork made by Rwandan children and art workshops for Charlottesville children hosted by the Rwanda Arts Collaborative throughout the month of October 2013.
UNICEF estimates that some 100,000 orphans live in youth-headed households in Rwanda. Recognizing the need to support the mental and emotional health of vulnerable children in Rwanda and the general prosperity of children everywhere, including Charlottesville, the Rwanda Arts Collaborative was created earlier this year. Renee Balfour, director and founder of Art With A Mission Charlottesville and Emmanual Nkurazanga, director of Art with a Mission Rwanda, worked together this year to facilitate art workshops for over 125 Rwandan children. The children’s artwork is on display in the McGuffey Art Center, Nau Hall, and OpenGrounds. 

The artwork will be available for sale, with all proceeds returning to the youth-headed households that produced them.
As I walked around the exhibit after the crowds were gone, I found myself lingering at almost every painting. It was hard not to be taken in by the vibrant colors and thick brush strokes that were common denominator of all the artwork on display. There was a rawness to each picture that seemed to be best captured by a quote from a Rwandan child that had been framed alongside one of the paintings: “Art raises me.”
I think that as promoters of public health, it can be hard at times to remember that we are first and foremost advocates of complete well-being. When we say that we support the flourishing of children, we are saying that we want much more for them than simply safe housing, adequate nutrition and access to clean water. We want to provide children with a means for narrating the spirit of their lives. By allowing young people to creatively reinterpret their day-to-day experience, we can foster a greater understanding of what it means to be an active member of a community. When we talk about art raising our hearts and minds, we are really saying that art broadens our perspective. We can nourish children's imaginations--and our own--when we offer them an opportunity to express themselves.

Tuesday, October 8, 2013

Report and Reflection: Dean’s Talk- Patrick Kyamanywa (Oct. 2nd, 2013)

Dean Patrick Kyamanywa strode to the front of the room, sat down on a stool, and peered out at his audience through his spectacles. Forty of us had collected at Open Grounds, a study and meeting space in the Corner building at the University of Virginia. The d├ęcor, heavy on granite, metal, and flat screens, was contemporary, perhaps even futurist. Images from Rwanda, land of a thousand hills, were projected all over the room. I felt like I was at a TED talk.

Dean Patrick is the Dean of Medicine at the National University of Rwanda. Over the past few years, there has been significant cross-talk between UVA and the National University of Rwanda. Several of my colleagues in the School of Medicine have had the opportunity to travel to Rwanda and learn about challenges in surgery and medical education outside America. All of them have come back raving about their time in Rwanda and most of them began seeking ways to return almost as soon as they came back!

Given the sci-fi feel of Open Grounds, I had expected a cool powerpoint presentation. Instead, Dean Patrick dazzled us all by speaking extemporaneously, only consulting his notes occasionally to ensure accuracy in his figures and quotations. His talk touched on several important issues. Most notably, he discussed the need for countries providing aid (whom he dubbed “The global North”) to seek input from the countries receiving aid (the “The global South”) regarding issues that need to be addressed in their country instead of being overtly prescriptive. Dean Patrick discussed several other aspects of international partnerships in the world of global health, noting how much Northern and Southern partners had to offer each other. He also made a compelling case for horizontal transfers of information: they allow for organizational independence in joint ventures as well as an efficient horizontal transfer of insight, and technology between southern partners.

I believe one marker of good speakers is that they leave you with more questions than answers. Dean Patrick did so by explicitly stating several questions for us to mull over during the discussion. One of his questions set me thinking: students who visit Rwanda gain immensely from the experience, but what do they give back?  

Several of the students in the audience had been recipients of scholarships that enabled us to travel abroad for research or mission trips. Personally, I had received three thousand dollars to conduct a small study in India. While there, I also had the opportunity to meet hundreds of my countrymen through weekly community health screenings. No book, no documentary, no public health class could have communicated to me the severity of health disparities in rural India or the enormity of the task before us like that summer’s work in India .

But was that really the best use of that money? What had I given back to India?

One of my most enduring memories from India is of an emaciated young boy who came up to me during a community health screening. He was thirteen years old, but looked like he was nine; his mother informed me that he had a weak heart. Slightly incredulous, I placed my shiny new stethoscope on his chest . “Lub-swoosh-dup….Lub-swoosh-dup….Lub-swoosh-dup...” went his ticker. There was no mistaking it: he had severe mitral regurgitation. I felt quite clever about my physical exam skills, but became quickly disenchanted when I realized that all I had done was label the child as a heart patient. After all, a valve replacement surgery costs at least half of his family’s earnings for an entire year! In all likelihood, the family would have to look on helplessly as his heart struggled with its leaky valve.

What good was my label to him?

Three thousand dollars could have paid for the surgeries of at least six children like him. Three thousand dollars may even have bought an ultrasound machine that cardiologists could use to monitor his condition. Three thousand dollars would easily pay for vaccination, vitamin supplementation, and deworming programs for him and all his classmates.

I blurted out a brief description of my time in India and asked the following question: “Transformative as the trip was for me, would the money have been better spent in more direct ways?”

Dean Patrick thought for a few seconds as he mulled over my question. To my relief, he smiled and then offered several arguments for why it was important to spend those three thousand dollars to provide me that experience. He argued that I had returned to UVA with a more sophisticated understanding of global health and with a fortified commitment to working on global health issues. Thus, he felt it was important to invest in a future generation of intellectuals from different fields who would grow to care about issues in the developing world based on their experiences during international research or mission trips. Hearing Dean Patrick’s answer made me feel grateful for the opportunities I had been given and reinforced what what is expected of me in the future. I am sure the other CGH scholars in the room felt the same way. I think everyone leaving the talk did so with their brain buzzing a touch more than usual.

Personally, I left thinking about how I would make those three thousand dollars count.

If you would also like to experience the challenges, joys, disappointments, and triumphs of research or service projects relevant to global health, do consider applying for a Center for Global Health scholarship. You can find out more at http://globalhealth.virginia.edu/. Information for the 2014 CGH Scholars Application Process will be available in the fall 2013.   In the meantime, please contact the Center with questions at 434.243.6383 or ctrglobalhealth@virginia.edu.