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tumblr_o4wpuqRvYP1vot8d2o1_1280This year, 15 first-year Geisel MD students and 2 TDI students embarked on a journey to Minnesota for spring break. We spent time in Minneapolis with the urban Indian Community and visited four different reservations across northern Minnesota. The trip gave us a glimpse into Indian history, culture, and health. You can read more about our spring break Indian Health Service trip on our blog.

tumblr_o4wpuqRvYP1vot8d2o1_1280This year, 15 first-year Geisel MD students and 2 TDI students embarked on a journey to Minnesota for spring break. We spent time in Minneapolis with the urban Indian Community and visited four different reservations across northern Minnesota. The trip gave us a glimpse into Indian history, culture, and health. You can read more about our spring break Indian Health Service trip on our blog.

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First-year medical student Adrianna Stanley writes about her experience working with the Free to Smile Foundation in Guatemala, where the group helped to put smiles on the faces of many children and their families.

by Adrianna Stanley '18

Hands shaking and mind racing, I took a deep breath and walked through the door.  As my eyes adjusted to the bright overhead lights, I began to take in my surroundings. Metal cabinets filled with gauze, syringes, and vials of medications lined the right wall of the room.  I shivered as I felt a cold breeze coming from the single-unit air conditioner – a stark contrast from the 80 degrees I had felt right before entering.  A rhythmic beeping in the back left corner of the room drew my gaze to a bright blue machine riddled with knobs, tubes, and monitors, all of which were gracefully handled by the pediatric anesthesiologist in the room. I turned my attention to the amazingly courageous and beautiful 4-month-old little boy lying on the somewhat out-of-date operating table in the center of the room.  I thought about Carolina, his mother, who traveled five hours from her village to seek help for her son.  As tears streamed down her face, she hugged me tight, and whispered “God bless you” just as I was about to walk into the operating room.  “Suture please.” I quickly snapped back to reality as the surgeon stared at me in anticipation. “Sutura por favor,” I instantly translated to Dina – our Guatemalan surgical tech who spoke no English.  For the next three hours, I circulated throughout the room, translated and retrieved materials for Dina, discussed the case with our anesthesiologist, and ultimately became entranced by the intricate artistry of the surgical procedure.  It was not until little Jose Miguel was safely awake and in the post-operative care unit that I sat down and thought to myself, “Okay, so that is what it’s like to be in an operating room for the first time.”

Geisel medical student Adrianna Stanley with one of patients and their mother in Guatemala.
Geisel medical student Adrianna Stanley with Antonia and her granddaughter Perla, one of Free to Smile patients in Guatemala.

My trip to Guatemala was a medical immersion experience like no other.  I traveled with Free to Smile – a non-profit organization dedicated to improving the lives of the world’s most underserved children through cleft lip and palate surgeries. As a first-year medical student on the team, I was guided by Dartmouth alumnus, Dr. Frank Virnelli, and asked to help with Spanish translation and any other auxiliary services they may need – whether it was in administration, nursing, dentistry, anesthesia, or surgery.  From the moment we stepped off the plane in Guatemala City, we hit the ground running.  A whirlwind of faces, backgrounds, and professions to keep straight – I’ll admit, I was intimidated at first.  On our team of surgeons, anesthesiologists, dentists, nurses, technicians, assistants, and administrative staff, I was by far the youngest and most inexperienced.  It was not until I started conversing with the locals, meeting our patients and their families, and translating for our team members that I finally felt I could connect with the community, contribute to our team, and truly make a difference.

The week began with triage day.  Stepping into the clinic, we encountered a large group of very scared, nervous, excited, and grateful families.  The vibrant colors of traditional Guatemalan dresses combined with the intricate slings in which the children were carried swiftly caught my attention as we moved through the crowd.  Many of these families had never been to Guatemala City, let alone seen a group of foreign faces before.  Free to Smile works with a local Guatemalan organization called Compañeros Para la Cirugia (Partners for Surgery) that sends health promoters into very rural communities of Guatemala to seek out potential candidates for surgery.  They arrange all accommodations and transport for patients and their families to the city, and they provide post-operative follow-up care and monitoring of patients after our medical team returns to the United States.  On our triage day we screened over fifty pediatric patients for surgical eligibility as well as provided dental consultations for each of their family members.  By the end of the day most of the nervous looks of anticipation that had greeted us in the morning had melted into quite a few toothless grins that really warmed my heart.

Over the next five days, I ran to wherever I was needed or could learn something new.  In the pre-operative care unit, I worked with our nurse to take patient histories and vitals.  With anesthesia, I learned about the process of intubation, inquired about the various anesthetics involved, and even assisted in stabilizing patients during the sedation process.  On the surgical team, I scrubbed in, passed instruments, and am eternally grateful to the surgeons who spent countless hours explaining their techniques to me.  Supporting the nursing team, I had a wide array of roles from circulating in the OR to changing diapers, placing suppositories, and drawing up medications for the patients post-operatively.  Most emotional for me, however, was my role in conducting interviews of patients’ families.  Learning about Carolina’s economic hardships, the lack of nutritional and pre-natal care for Perla’s mother, the community’s heartless reaction to the birth of Maria Jose’s daughter, and the physical abuses rampant in these Guatemalan villages truly broke my heart.  Hearing their stories also made me think critically about the social and economic disparities that lie at the foundation of these medical problems and their role in shaping the way we deliver global health effectively.  I appreciate the work of Free to Smile for their continual presence in Guatemala, their cohesive partnership with local Guatemalan organizations, and their vested interest in improving all aspects of the lives of the underserved.

Ultimately, I am honored to say that over the week we successfully completed 41 surgeries – 12 cleft palate and 29 cleft lip repairs.  The lives of these children will be changed forever, as they now have the capacity to develop their speech normally, go to school without ridicule, grow up with confidence, and bring the option of a better life to their families.  Being a part of this team, connecting with the patients and their families, and reflecting on my own family’s struggles with poverty in Central America has truly reminded me of why I chose to become a physician in the first place – something often forgotten by medical students constantly buried in textbooks and exams.  I look forward to many more global health experiences in the future and a life-long career of giving back to my own underserved Latin American community so that they can achieve the human right to health that they deserve.

A huge thank you to Stacy Henry and the Free to Smile Foundation, Compañeros Para la Cirugia, Dr. Frank Virnelli, Dr. Lisa Adams, Dartmouth’s Center for Health Equity, the Geisel School of Medicine, and everyone on my team for supporting me and providing me with the experience of a lifetime in Guatemala!

Members of Geisel's Urban Health Scholars program reflect on a chance to explore the challenges and rewards of working with underserved populations.
Greater Lawrence Family Health Center
The Urban Health Scholars at the Greater Lawrence Family Health Center.

In early September, members of Geisel's Urban Health Scholars program traveled to Massachusetts to attend several events that would give them a sample of some of the challenges and rewards of working with underserved populations in urban areas. A few of the scholars reflected on what they took away from the experience.

Thursday, September 4

Greater Lawrence Family Health Center
By Ali Corley (’17)

Our first stop on our 2014 Boston immersion trip was the Greater Lawrence Family Health Center (GLFHC) in Lawrence, Mass., just north of Boston. There we met with Dr. John Raser, a graduate of Dartmouth College and the Medical School, who showed us around and spoke about his work there. Dr. Raser is a family medicine doctor who lives and works in Lawrence and is an advocate for his patients both at the center and in the community. On our tour of the health center, Dr. Raser told us more about GLFHC and the type of medical care they provide. GLFHC has adopted a patient-centered medical home model, which emphasizes teamwork among health professionals and addresses health issues from many perspectives. They promote group health sessions, healthy lifestyles, and community-wide interventions to improve health in a lasting and effective way.

Dr. Raser discussed the importance of health professionals being involved in the communities that they work and live in. Doctors have great potential to be local leaders and can use their knowledge and respected positions to initiate healthy programs and initiatives. In fact, Dr. Raser recently started a project to open a bike shop in the community. We detoured along our tour of the health center to visit his shop, BiciCocina, which he started to fill the need of the city, which hasn’t had an operating bike shop open in several years. With BiciCocina, Dr. Raser hopes to promote active lifestyles and safe streets through youth programs and community events. We took the scenic route back to the health center and had the opportunity to walk through some of the Lawrence center streets and the common park. Lawrence is a unique combination of city and small town. We saw Italian, Greek, Irish, Dominican, and Haitian churches and buildings and were able to appreciate the diversity of the Lawrence population.

Back at the center, Dr. Andy Smith joined us for dinner and discussion. Dr. Smith spoke to us about the overlap between urban and global health and gave us a presentation about the qualities required to deliver care in both settings while also managing to maintain optimism, idealism and compassion. We learned about the special challenges that come with working in a primarily Dominican community and how the ability to relate to patients is enhanced when you speak their language or have been to their home country. Dr. Smith told us about cultural differences concerning patient-doctor relationships and how the strict professionalism we are taught in school may need to be adjusted depending on the patient. For example, he greets some of his patients with a hug and kiss on the cheek, which is custom in many Latino cultures. For others, he finds that showing them pictures of his family helps strengthen his relationship with patients and break down barriers to trust.

The Greater Lawrence Family Health Center offers programs for residency training and rotations in family medicine, with opportunities for Spanish language learning and immersion. After our vist to Lawrence today, I think many of us will consider pursuing these opportunities in our third or fourth years and beyond.

Friday, September 5

Revitalizing the Hennigan Elementary School with Harvard Pilgrim, the Celtics, and City Year
By Brendin Beaulieu-Jones (’18)

We kicked off the second day of our Boston immersion trip at Hennigan James Elementary School, where we joined Harvard Pilgrim, the Boston Celtics, and City Year for a morning of community service. Before jumping into the work, we heard from the principal of Hennigan James Elementary School, who stressed the importance of providing a warm, learning environment for children in order to contribute to a healthier, stronger community. The school is currently expanding to include sixth- through eighth-graders, and it serves as a pre-K learning center, Boys and Girls Club, and recreational center for the community.

After some additional opening remarks by the presidents of both the Celtics and Harvard Pilgrim, we enjoyed some brief entertainment by Lucky the Leprechaun (the mascot of the Boston Celtics) before heading out to start our work. A few of us painted the exterior of the school, including the courtyard, four-square courts, and main entrance, while others removed some weeds and debris from the neighboring fields. It was refreshing to have the opportunity to serve the Jamaica Plain community and help contribute to a more positive learning environment at Hennigan.

Meeting with Dr. Megan Sandel
By Hayley Jones (’17)

After an exciting morning working with the Boston Celtics and Harvard Pilgrim at the Building Healthy Communities day of service in Jamaica Plain, we headed to Boston University’s medical school to meet with Dr. Megan Sandel, a graduate of Dartmouth's medical school, for a Q&A about Boston’s Medical-Legal Partnership. Dr. Sandel’s enthusiasm and understanding of the social determinants of health were engaging and exciting to hear about. Even better, work that she has done has helped to create laws that holds landlords in Boston responsible for basic upkeep so that apartments in Boston are less likely to make people sick. The law addresses mold, mice, and other infestations that can adversely affect the health of inhabitants. Dr. Sandel’s exuberance for understanding how housing status affects health outcomes from children to HIV positive individuals was outstripped only by her determination to search for a solution. UHS took away much more than information from the Q&A.

Boston Health Care for the Homeless
By Cristina Alcorta (’17)

On Friday afternoon, we had the opportunity to meet with Dr. Jim O'Connell, President and one of the founding physicians for the Boston Health Care for the Homeless Program (BHCHP). We were very much looking forward to meeting the man who established the nation's first medical respite program for homeless persons and implemented the first electronic medical record for a homeless program.

With open arms, he welcomed us to his brainchild. Starting our tour off with a little history, Dr. O'Connell brought us to the historic main entrance of the old Mallory Building, describing its historical roots as Boston's center for medical pathology research and city morgue from the 1930s to the 1990s. We then shuffled to a conference room for a discussion about homeless health care and street medicine. Here, we learned about the Family Van, which brings necessary items such as blankets and warm soup to individuals on the streets. Dr. O'Connell feels that it is important not to offer medical services right away, because homeless individuals are often wary of the medical system. "They feel like they are going to get locked up, or taken away," he explained. Instead, Dr. O'Connell simply lets them know he is a physician as he leaves and that they can approach him if they ever want or need to.

Under the Affordable Care Act, affordable insurance is no longer an issue for the homeless. However, that does not mean problems have subsided. Ten percent of the BHCHP participants are chronically homeless. That is, they have been living in the streets for over one year. Fifty percent of the first-come-first-served beds taken up each night are used by that ten percent. Individuals not only need services, but support to find housing and manage a stable household. Unfortunately, many do not find the support they need to be on their own. Many do not find comfort in shelters: some fear large crowds; couples refuse to be split up; others feel enclosed. A patient once said to Dr. O'Connell, "I do not like the shelter because I cannot tell which voices are mine. . . . When I'm on the street I know which are mine and which aren't."

In addition, the majority of homeless individuals suffer from major, incapacitating mental illness. Those suffering from substance abuse have a difficult time staying sober and continuously fall back into the cycle of hard-core, chronic addiction. Overall, mortality rates continue to be high.

Our tour continued. A personable, compassionate man, Dr. O'Connell stopped at various points during our tour to introduce us to a patient or a dermatology resident to get a glimpse of their experience with the BHCHP. He shared deep and personal stories of the homeless individuals he has met throughout his time with BHCHP which encompassed both sad and triumphant anecdotes of his dearest patients. We saw several facilities, including the dental offices, pharmacy, inpatient floors, and the outdoor patio meant for moments of relaxation.

At each stop, we learned about the several services offered to patients: dentures, medications, prenatal care, walking aids, and initiatives to accommodate transgender individuals. We saw the rooms where patients slept and the rooms where they played bingo, cards, and pool. Though the homeless world faces strenuous trials each day, BHCHP seems to provide at least an iota of stability and calm in a sea of chaos.

Some of the hallways proudly display photos of the smiling faces of former patients of the BHCHP. "Turns out they wanted to have their pictures taken. It made them happy," said Dr. O'Connell. Most, however, had already passed away at too young an age.

Mattapan Healthcare Revival
By Fernando Vazquez (’18)

“When you connect with Mattapan Community Health Center, good things happen.” The organization’s motto is quite the understatement. For nearly 20 years, Mattapan Community Health Center has been organizing a revival; a festival centered on enabling community members to become more competent in taking charge of their health. From cholesterol screenings to dental checks, the event brings together an underserved community and not only educates them, but also urges attendees to spread the word to neighbors that help is available to all. Geisel’s Urban Health Scholars capped an immersion weekend with the valuable lesson in the importance of true integration into the communities we will go on to heal and serve.

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Over the past couple of weeks, Tara Kedia ('17) has been finishing up her work in Haiti, and she has also had the chance to see more of the country.

By Tara Kedia

In my last couple of weeks in Haiti, I’ve been concluding my projects at l’Hôpital Immaculée Conception (HIC), and have also had the chance to see a bit more of the country. (Read more about my work at HIC in my previous post.)

Mixing the first batch of hand sanitizer. Enough to prove the concept, but not enough to supply a hospital.
Mixing the first batch of hand sanitizer. It is enough to prove the concept, but not enough to supply a hospital.

Some of the departments at HIC do not have consistent access to soap and water or hand sanitizer, which are important infection-prevention measures. Last week, my supervisor, Cleonas Destine, an infectious disease doctor here at HIC, and I mixed up a batch of hand sanitizer, as per the World Health Organization’s Formulation. We still need to find a pharmacy in Cayes that would be able to mix larger batches to continuously supply HIC with hand sanitizer.

The projects on tuberculosis diagnosis have also progressed further along. We have gotten comments from all the TB staff and infectious disease doctors on a shorter and translated-to-Creole version of USAID’s survey, “Reducing Delays in TB Diagnosis." This week, we’re meeting with the staff who could administer this survey to patients on a regular basis.

With the help of Cleonas and the TB staff, I have also learned a lot about the use of GeneXpert at HIC. Our research has been a bit challenging, as information on HIC’s TB patients is spread between three paper record books, an electronic lab register, and individual patient files (both electronic and paper), as well as the files at satellite clinics. I was able to visit one of these satellite clinics, the TB Sanatorium. The Sanatorium in Cayes is one of only a handful of sanatoriums that still exist in Haiti. The patients who stay here are being retreated for TB, so an additional antibiotic must be added to their treatment regimen. Because this antibiotic can only be administered by daily injections, these patients must stay at the sanatorium for the 60 days of their treatment. Worldwide, sanatoriums are being shut down or repurposed. The Cayes Sanatorium might become a general infectious diseases clinic.

Sanatorium
Sanatoriums were typically built in the mountains, as it was believed that the cool, fresh mountain air circulating through the building would cure TB patients. This has since been disproved (antibiotics cure TB), but the view from the Sanatorium in Cayes probably lifts the patients’ spirits.

Outside of work, I’ve gotten to see a bit of the regions around Cayes. This past weekend I went on an epic excursion organized by the students of the university where my host mother works. There were maybe 50 of us in a school bus, and we drove two hours west from Cayes to Port-à-Piment, the town where the Marie-Jeanne Cave is located. It’s over four kilometers long, and it is the largest cave in Haiti. All of us went with one guide into five rooms of the cave, two of which had natural light, and three of which were too far underground and so were pitch black, requiring flashlights (or, in our case, the flashlight app on our phones) to navigate. Most phones in Haiti are pretty basic (very few smartphones or flip phones), but they have a great extra feature, a penlight at the top, that is indispensable for things like power outages and, this weekend, navigating caves. Unfortunately none of my photos in the caves came out, but they were amazing and worth an online search of “La Grotte Marie-Jeanne” if you’d like to learn more.

After visiting the caves, we got back on the bus to visit Les 500 Marches de la Medaille Miraculeuse in the town of Côteaux, which are 500 stairs up the side of a mountain, at the top of which is a statue of the Virgin Mary. As the story goes, she was seen at this place once upon a time. After climbing the stairs, we drove to Port Salut, a beautiful beach, for lunch and swimming.

Port Salut
Caption: Everyone who I’ve spoken to has said they prefer swimming at Port Salut (an hour’s drive from Cayes) rather than Gelée, the beach right outside of the city center. It’s certainly spectacular, with some of the bluest water I’ve ever seen.

In all, I can’t believe my time in Haiti is coming to a close. It feels as though I’ve just arrived—one month is not such a long time, after all. There have been challenging things about my experience here—the frequent and unannounced power outages (including for five days last week, making it difficult for me and especially the doctors to work), and the questions I am asking myself about the roles I can most usefully play in global health work in the future. There have also been amazing things about my experience here—the opportunity to assist in research that can improve TB care for patients, the ability to practice my French, and the close community of Haitians living in Cayes. I feel like I’ve just started to get a good taste of that community during my last week or two here, and for that I am profoundly grateful to everyone who has welcomed me. Merci à tous qui m’ont accueilli ici aux Cayes! Vous allez me manquez beaucoup.

Tara Kedia (’17) earned a BA in Anthropology and Biology from Dartmouth College. She previously interned at the World Health Organization and at the DarDar Pediatric HIV Clinic in Dar es Salaam, Tanzania.

As she prepares to leave Tanzania, Auriel August reflects on her experiences, from conducting a clinical study to exploring local cultures.

By Auriel August

Over the summer of 2014, Auriel August (’17) conducted research at the DarDar Pediatric Program in Dar es Salaam, Tanzania. Read all of her posts here.

Squeezing in one last patient on my last day at DPP, I was able to reach my target of 50 to include in the trial! Now I will begin a preliminary analysis of the data collected, looking at various parameters (e.g. age, years of antiretroviral therapy, history of TB) and their effect on forced expiratory volume and forced vital capacity. Hopefully, we will be able to replicate the results from the previous studies done in other East African countries.

Auriel August
Auriel August (right) with Dr. Anna Kiravu.

Unfortunately, the time has come for me to leave Dar Es Salaam. As I pack up my room, I reflect on my six weeks in Tanzania. I attended a traditional Tanzanian send-off party for the daughter of a nurse with the DarDar Pediatric Project, swam with dolphins off the southern coast of Zanzibar, and explored the natural wildlife of the Serengeti. But most importantly, I got to spend every day working with incredible children living with a very serious and extremely stigmatized illness. I have learned far more than I could ever contribute, but it is my hope that the project can at least draw some attention to the well-being of HIV-infected youth in Tanzania. I feel privileged to have had the opportunity to live and learn in this community, and I will forever carry my experiences with me.

I want to give a special thank you to Dr. Paul Palumbo and Dr. Margaret Guill for incorporating me into their project and advising me over the past year, as well as Dr. Anna Kiravu and Dr. Yahya Binde for their mentorship while I was in Dar and their incredible patience as I struggled to communicate in Swahili. I would also like to thank Dr. Helga Naburi and Dr. Isabella Sylvester for allowing me to round with them at Muhimbili National Hospital. Finally, I want to thank the Dickey Center and Helen’s Fund at the Children’s Hospital at Dartmouth for supporting my project.

Even though I have not yet left Tanzania, I am already looking forward to my next trip back.

Auriel August is a member of the Class of 2017 at the Geisel School of Medicine.

The past two weeks have been filled with new experiences for Auriel August ('17).
Auriel August
Auriel August at the rim of the Ngorongoro Crater.

By Auriel August

Over the summer of 2014, Auriel August (’17) will be conducting research at the DarDar Pediatric Program in Dar es Salaam, Tanzania. Read all of her posts here.

The two weeks since my last post have been filled with so many new experiences!

I was given the opportunity to conduct rounds with Dr. Helga Naburi in the neonatal unit at Muhimbili National Hospital. She explained pregnancy complications that are common in the region, such as birth asphyxia, and how doctors go about treating the preterm babies without access to incubators or ventilators. There is an amazing team of physicians and nurses in the wards who do great work with limited resources.

In addition to visiting the neonatal ward, I joined Dr. Isabella Sylvester for rounds on the pediatric malnutrition ward, a unit that unfortunately sees quite a few patients. She introduced the different presentations of acute malnutrition and explained that their work focuses just as much on educating caretakers about nutrition as it does supplying medicine and supplements. I learned an incredible amount in just a few days and I am already hoping to return to Muhimbili to complete an elective rotation in my fourth year.

Back at the DarDar Pediatric Project, I continue to enroll patients in the study and have begun to compile the completed data. I was able to complete a large cohort of patients at the adolescent clinic that meets on the weekend, but I am still a few patients short of my target goal. I am quickly learning that clinical research does not often proceed at the pace in which you would like and therefore requires a lot of patience! While popularized by the Disney movie The Lion King, the phrase “hakuna matata” ("no worries"), is a way of life here in Tanzania and I have graciously adopted it. As the data begins to take shape, I am interested to see what it will tell us about the lung function of youth living with HIV.

An elephant herd in Taragire National Park.
An elephant herd in Tarangire National Park.

This past weekend I visited the Kilimanjaro region of northern Tanzanian to go on safari and visit the Masai lands. The difference between the bustling metropolis of Dar es Salaam and the more rural town of Arusha and the untouched lands of the Ngorongoro crater is striking. It was a privilege to see the incredible wildlife living in the national parks and experience the culture of the Masai people. I am sad to realize that my time in Dar is almost over.

A Masai market outside Arusha.
A Masai market outside Arusha.

Auriel August is a member of the Class of 2017 at the Geisel School of Medicine.

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Last week, Tara Kedia ('17) arrived in Les Cayes, Haiti, where she will be working for the next month on two public health projects related to tuberculosis.

By Tara Kedia

Last week, I arrived in Les Cayes, Haiti, where I will be working for the next month at Hôpital Immaculée Conception (HIC), the public hospital for Les Cayes and surrounding regions. Les Cayes is the capital of the South department of Haiti, with a population of over 125,000 in 2009. The official languages of Haiti are French (spoken in more formal settings) and Haitian Creole (the lingua franca). I do speak French, which has been a big help, but I’m still struggling to understand Haitian Creole so I can communicate with everyone here.

Haiti map
Kedia landed in Port-au-Prince and travelled by car to Les Cayes, about a three-hour journey through the mountains and along the coast. Map from Wikimedia Commons/Rémi Kaupp. (Click to enlarge.)

I first learned about Dartmouth’s affiliation with HIC while seeking an opportunity to assist in global health work during the summer between my first and second years of medical school. I was connected with Dr. Peter Wright and Dr. Elizabeth Talbot, who are serving as advisors to my work at HIC. I’ve also spoken a great deal with Kristen Jogerst (Geisel ’16), currently a third-year medical student who worked at HIC last summer and who introduced me to the wonderful family who is hosting me during my month in Cayes.

Les Cayes
The family Kedia is staying with lives outside of the city center. Their home overlooks farm fields and, in the distance, the mountains. Much of Haiti is mountainous but Cayes itself is quite flat.

While here, I’ll be working on two projects concerning tuberculosis (TB). One project is aimed at better understanding the use of GeneXpert at HIC. GeneXpert is a novel diagnostic device, about the size of a desktop computer, with high sensitivity and specificity for TB. Within two hours, GeneXpert simultaneously diagnoses and determines resistance to the first-line TB drug rifampin. GeneXpert is a huge improvement on earlier tests. Previously, labs had to test for TB and drug resistance separately, and there were many more missed TB cases (false negatives). The GeneXpert machine arrived at HIC in 2013 thanks to funds from the Centers for Disease Control and Prevention (CDC) and the Global Fund. Since being endorsed by the World Health Organization in 2010, GeneXpert has been rolled out internationally, and roll-out is in progress in Haiti.

Tara Kedia
Kedia is working in the Infectious Diseases Clinic of HIC.

The other major project I’ll be working on is a study of the causes of delays in TB diagnosis for patients in HIC’s catchment area. The ultimate goal is to use what we learn to mitigate the factors that contribute to diagnosis delays in and around Les Cayes. This work is important because the longer patients with active TB go undiagnosed, the more their TB can spread to those around them. So diagnosing (and treating) a patient sooner effectively stems the spread of TB bacteria and disease.

I’m very glad to be working on these projects at HIC, as I interned in the Stop TB Department of the World Health Organization (WHO) Headquarters in Geneva, Switzerland, for six months in 2012. I assisted in updating the WHO’s recently released 2014 Guidance for National TB Programmes on the Management of TB in Children, 2nd ed. Given my perspective on TB from the level of the WHO, I’m looking forward to learning more about the practical side of TB care and diagnosis at HIC.

Tara Kedia (’17) earned a BA in Anthropology and Biology from Dartmouth College. She previously interned at the World Health Organization and at the DarDar Pediatric HIV Clinic in Dar es Salaam, Tanzania.

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This summer, medical student Tiffany Hoang ('17) is helping to implement a text message-based program to promote maternal health in Vietnam.
Hanoi
The skyline of Hanoi, Vietnam. Photo by Choithuxem/Wikimedia Commons.

By Tiffany Hoang

This summer, I am spending five weeks in Hanoi, Vietnam, working with the Institute for Population, Development, and Health (PHAD). My responsibilities include providing support for the mMOM project, which is piloting a SMS-based program to improve maternal health for ethnic minorities. The project is centered in the mountainous area of Thai Nguyen, which is about 75 km from Hanoi.

Thai Nguyen has a significant ethnic minority population that has traditionally faced a number of challenges compared to the ethnic majority (Kinh), including receiving subpar health care, having lower income and less education, and living in more remote areas. The Vietnamese government has taken steps to try to bridge health-care gaps between the ethnic minority and majority. In the mMOM project, expecting mothers and new mothers receive SMS (text) messages with health information and reminders. With the increasing use and availability of cell phones, this project has much promise to improve maternal and child health in the ethnic minority population.

What initially drew me to this project was the use of SMS and technology to reach out to a population that has traditionally been underserved. As I am doing more research in the field, I am fascinated by the difficulties and questions that arise, such as the ability of mothers to read the SMS messages, whether the mothers are able to reach a health-care facility, and the retention rate of the information sent to the mothers. As the project continues, answers to these questions and concerns will become known.

In addition to my work with PHAD, I am shadowing physicians at the National Pediatric Hospital in Hanoi. It is the premiere pediatric hospital in the area and patients come from hours away to be treated. I will be shadowing the emergency, infectious diseases, and surgical departments. I look forward to learning more about the health care of Vietnam both through my work with the mMOM project and through observation at the National Pediatric Hospital.

On a more personal note, I have been in Hanoi for two weeks, and I am loving every minute of it. It is very different from the quiet streets of Hanover and from the bustling freeways of Los Angeles, where I am from. Motor bikes and cars stop for no one, so crossing the street is a precarious task. The food is divine. I am fortunate to do a home stay during my time in Hanoi. That means I can enjoy home-cooked Vietnamese food every day! I've had my fair share of bún nem rán (vermicelli noodles with egg rolls and fish sauce), cơm (rice), trái vải (lychee), trái mít (jackfruit), and much more over the past couple weeks. I am extremely excited to learn more about all aspects of Vietnamese culture over the next month!

Tiffany Hoang is a member of the Class of 2017 at Geisel and a member of the Urban Health Scholars. Her work in Vietnam is funded by the Global Health Initiative at the Dickey Center for International Understanding.

Auriel August ('17) writes about her first day of work at the DarDar Pediatric Clinic in Dar es Salaam, Tanzania.
Auriel August at the DarDar Pediatric Program.
Auriel August at the DarDar Pediatric Program.

By Auriel August

Over the summer of 2014, Auriel August ('17) will be conducting research at the DarDar Pediatric Program in Dar es Salaam, Tanzania. Read all of her posts here.

It did not take long to learn the most popular greeting in Dar es Salaam: “Mambo,” meaning “Hi, how are you?” Typically, you respond with “Poa poa,” which means “Cool.”

Multiple greetings are very common in Tanzanian culture. Usually when you meet someone you start with the mambo/poa exchange, and then you ask how they slept or how their morning was and if they are having a good day. The interest is genuine—people are really interested in each other’s wellbeing and state of mind throughout the day.

The tools August uses to conduct her research.
The tools August uses to conduct her research.

My work at the DarDar Pediatric Program is going surprisingly well. I expected it to take some time to settle in, but I was thrown right into the mix on the first day. I am working with Dr. Paul Palumbo and Dr. Margaret Guill from Dartmouth, and with a Tanzanian pediatric resident—Dr. Yahaya Binde—on an investigation of the pulmonary function of HIV-positive youth in Tanzania. In recent years, studies have indicated that children with HIV exhibit abnormal lung function. It had not previously been shown that HIV directly affects lung function (at least in the absence of pulmonary infections such as pneumonia or tuberculosis), so Drs. Palumbo, Guill, and Binde are interested in investigating further.

To conduct the trials, I use a spirometer to measure the forced expiratory volume (FEV1) and forced vital capacity (FVC) of children between the ages of eight and eighteen before and after exercise, as well as after administering a bronchilator (a medication that increases airflow to the lungs) to the children. Then I take these values and compare them to the predicted values for East African children based on each child’s height.

Auriel August is a member of the Class of 2017 at the Geisel School of Medicine.

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Peace Eneh ('17) finds that life in Lagos is fast-paced and intense, and it can help to have local partners to navigate the complexities of the local health-care system.
Lagos, Nigeria (Shutterstock)
Lagos, Nigeria (Shutterstock)

By Peace Eneh

Over the summer of 2014, Peace Eneh is working on a survey of knowledge of cancer among physicians and medical students in Nigeria. Read all the posts about her experience here.

Lagos is like New York but more intense. It’s the biggest city in Africa and has a booming economy to match its fast pace of life. There is so much energy. Lagosians are go-getters. The day usually begins around 5:00 a.m. and ends very late at night.

When I step out of the apartment in the morning, I am greeted by an intense sun. As I walk to the bus stop I am enveloped in a frenzy of activities. Everyone is going about their business; there’s so much buying and selling. I even have to jump onto the bus as it moves. Yes, it’s true. I literally have to jump onto a moving bus because everything is in motion. Some of the buses slow down just enough for people to jump off and on. It seems to be regarded as a waste of time to come to a complete stop in this fast-paced city.

While it might seem like there are not enough buses to take people around, the truth is that there are just too many people and too many cars and buses going to too many different places. This causes the roads to be packed at all times. The traffic jams are ridiculously crazy. If you are not ready to be in traffic for at least three hours on any given day, then you would be better off staying at home. And if you are not fit to jump onto a moving vehicle, please visit the gym and try again later.

Yet while the city of Lagos moves at a fast tempo, the systems in place to serve the people are slow and unpredictable. For instance, the internal workings of the Lagos State University Teaching Hospital (LASUTH), the hospital where I am doing my cancer research, can be very slow. As a government-owned hospital, the fees for service are usually subsidized. The hospital therefore has a high patient volume but is understaffed. The wait times are long and the waiting lines are even longer.

I recently visited the cancer clinic, which is run every Tuesday and Friday. There were more patients than could possibly be seen in a single day and there were very few doctors available. The patients who could not be seen on Tuesday have to come back on Friday, and if they are not so lucky they might need to come back again on another day.

Peace Eneh and Dennis Hogan
Peace Eneh with Dr. Dennis Hogan, who has helped her navigate the health-care system in Nigeria

This is the same story that we hear all the time about challenges with health-care delivery in resource-limited settings. However, there are also stories of major advancements that are being made that are often neglected. One example is about the Access to Basic Health Care program (ABC for short). The ABC program was started by the wife of the governor of Oyo State in Nigeria. Ibadan is the capital city of Oyo and is very close to Lagos. The ABC program offers free health services to the locals. There are 10 locations within the city of Ibadan and there is access to screening, consultation, and treatment. Each location has a local staff that speaks the language and understands the people and the culture. The offices are equipped with a computer program that helps with the diagnosis of diseases that can be easily treated and managed by the resident nurse. There is one physician in charge of every three units.

One of the physicians is a friend that I know from high school, so I was able to tag along to observe how the clinics are run. Every patient that comes in with malaria symptoms gets tested with their rapid diagnostic tool (RDT). With RDT, a diagnosis of malaria is made in less than five minutes. They are then able to start treatment immediately. They also found that, since these clinics opened, more patients have been able to seek medical attention because it is easily accessible and free to them.

The clinics employ nurses to help with the management of common illnesses like malaria, intestinal worms, and many bacterial infections. The nurses make the initial assessment and leave the more challenging cases for the physicians, thereby reducing the physicians’ work volume and saving time and money. Otherwise, the physicians would be swamped by the multitude of patients waiting for treatment.

I asked my friend about the sustainability of this project. It seems like this aspect of the clinic still needs to be worked out, but in the meantime there is something being done to improve access. We as rising physicians have to look at what is being done, what is already on the ground, and find ways to make these processes better and sustainable.

My cancer education research has been going on for a few weeks now and I have already learned the value of local partnership. Not just any partner, but one who speaks the language. I am referring not just to the local language of the people in the area but also to the language of the system and the institution. This will make your life exponentially easier.

My partner is Dr. Dennis Hogan. He is definitely knows his way around LASUTH. He is very friendly and professional and knows how to speak LASUTH. I pretty much let him do a big chunk of the talking, because as soon as I try to explain anything, the people quickly recognize that I am not from the area and either try to make things more challenging or they ask me to go and see someone else.

Don’t get me wrong, coming from the U.S. definitely carries prestige, and people are willing to entertain questions and even listen to what I have to say. But there are many protocols and paperwork. When someone tells you to go see a certain person, it could be a coded way of telling you that might have to sweet talk that person to get the necessary permissions.

With the help of Dr. Hogan and other local collaborators, I have been able to obtain the necessary approvals that I need, and my project is well on the way to being completed. One of the medical students helped us go from room to room to identify and survey the medical students and one of our local collaborators got his colleagues to complete the surveys for the physicians.

So I will leave you for now with this very important lesson: local collaboration and partnership is invaluable to a successful global health experience.

Originally from Nigeria, Peace Eneh (’17) moved to the U.S. in 2007 to attend Concordia College in Minnesota. She spent two years working as a clinical research coordinator at Masschusetts General Hospital before arriving at Geisel in the fall of 2013.