Utah Valley Global Health Group

A blog about global health for those living in Utah Valley and their friends.

Archive for the ‘Global Health Topics’ Category

Karl Kirby and Rising Star Outreach: Experiences with Leprosy in India

Posted by chads on April 14, 2009

To introduce myself, I’m currently serving as the medical director for Rising Star Outreach (RSO) in India. Chad has asked that I post something about what I”ve been doing over the past 8 months. It’s very difficult to know where to start, but I’m going to give it a shot and then follow-up with more, depending on the questions that follow. I have no special training in tropical medicine or public health, just a long-standing desire to be involved in improving the health care for those most in need. So, I’ll be happy to hear from others with more experience and/or training who have suggestions and comments. I am a family-medicine trained physician and spent the first four years of my career as the physician of a rural Community Health Center in Na’alehu Hawaii. After that, my wife and I felt it was time to do what we’d always said we’d do – find an organization who needed our services in a developing nation. Through Chad, we discovered a need with Rising Star that fit perfectly with our skills and desires. Rising Star Outreach exists to try to assist those who have been afffected by leprosy (although I’m aware that the term Hanson’s disease is preferred among some, I’ll continue to use the term leprosy in this posting because it is the term commonly used here in India). While I work on the medical side of the organization, my wife (who has an education background) assists at the school.

In India, RSO runs a mobile clinic in an attempt to improve the healthcare for the seven colonies it services. At the same time, RSO administers microloans to leprosy afflicted infividuals and offers a boarding school to some of the children from the colonies. I live with my wife and 3 small children on the rural RSO property which also houses the children’s hostels and school. My responsibilities include overseeing the mobile clinic and medical services on site for the children (and other employees). I work closely with a local physician, who is trained as a general practicioner, and a local nurse.

In India, the rates of new leprosy cases are very low. The Indian government and the WHO have made huge efforts to encourage early detection and treatment which are now paying off. The patients whom I treat are not people with active leprosy, but rather people who acquired the disease many years ago, did not receive prompt treatment, and now suffer various disabilities because of it. Because of the nerve damage that has taken place, many of the patients suffer from chronic ulcers, primarily on their lower extremeties. One of our big goals has been to try to find a better way to help these wounds heal. Having done a little extra training in woundcare before arriving, I had certain ideas about what needed to be done to improve healing. However, I soon realized the difficulty in transferring these techniques – the main barriers were lack of similar materials and also the low frequency of our visits.

About a year ago, I was introduced to a surgeon from Mumbai, Dr. Atul Shah, who was holding “camps” to help similarly afflicted individuals treat their wounds. He was giving instruction sessions and handing out small packets with a callous file, bandages, antisceptic, and antibiotic ointment. He was reporting good results through this self-care program. At first I was a little skeptical that this could really have the impact I was looking for, but after several months of treating these patients with little success, I began to see the wisdom in this program. With it’s focus firmly on self-reliance, it fits in well with our efforts to educate the children of the colonies and encourage financial independence.

So, in January, we put together our own self-care kits, and started rolling out this program to the seven colonies we visit. Each colony is visited every 2 weeks. In the past these visits included consultation with the physician and the dispensing of basic medications for general problems as well as bandage changes for those in need. We also provide transportation to a private hospital in Chennai, Sri Ramachandra Medical Center, two or three times a month for patients needing specialty care, procedures, or hospitalization. (This gives them another option for care outside of the government system.) Now, in addition to the other services provided, we meet individually with each patient to assess their wounds which we are following with digital photos. It allows us to provide specific encouragement and reinstruction as they look at their initial photo on our laptop and view the current wound. We’re currently midway through what should be a 4 month program in several of the colonies, with the larger of our 2 colonies being about a month into it. It’s been very exciting to discover that many of the patients are making very good progress, while I saw very little progress in the months before the program. To me, this is a great example of the effectiveness of a simple program that places responsibility with the patients. Clinically, I believe the program is working because it encourages a gradual removal of old deep callous (through soaking the feet and using the callous file) so that it can be replaced with more viable tissue, and it simply encourages more regular care of the wounds.

In addition to the work in the colonies, caring for the medical needs of the 125 boarding students has been a treat. They are a fun group of children who always pose the challenge of figuring out whether they have a serious medical problem that day or just want a little more attention. Thus far, we’ve avoided anything catastrophic, although we’ve had our share of fractures, lacerations, common pediatric infections, and single cases of scopion envenomation, slipped capital femoral epiphysis, and clinically significant Hepatitis A, and Typhoid fever. We’ve begun a program, with the kind help of a local pediatrician, to provide immunizations to the children which are not on the government schedule (next up is Typhoid) which I’m very pleased with. Dr. Jayakumar drives about 40 minutes and provides staff and vaccinnes each month to assist us in this project. We became acquainted when I started taking my own son to him for his 1-year vaccinations.

So, overall, this has been a wonderful experience for me. I have no delusions that the service I offer is any greater than the growth I’m gaining through the medical experiences I’m having as well as the personal growth that comes with service. Hopefully, with the help of others, this can be one step toward increasingly more effective interventions as we strive to assist those with the greatest medical needs.

On another note, RSO is very interested in keeping a health-care professional on campus once I leave. I will be coming back to Utah in May. While the local physician and nurse will still be running the medical services, they live about 40 minutes from campus. To manage the urgent, or potentially emergent, problems that arise with the children and employees, RSO would like to keep a healt-care provider on site. This could be a physician, a PA, a nurse practitioner, or an experienced nurse or EMT. They would also get to assist with the work of the mobile clnic. We are looking for someone who could commit to staying for a significant period of time (close to a year or more). If you or anyone you know is interested, please let me know.

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Posted in Announcements, Clinical Tropical Medicine, Guest Bloggers, humanitarian aid, Leprosy, NGOs | 4 Comments »

Best websites: Resources for teaching, presenting or learning global health

Posted by ryanlindsay on March 11, 2009

Chad’s previous post of Hans Rosling’s TED talk reminded me of a list that I have been wanting to post for a while. Below are some of my favorite resources that I have used to help explain or present global health issues. These websites have been passed on to me from past professors and friends. If you have something to add then please share in the comments!

Gapminder
Be your own Hans Rosling and create bubble plots with all sorts of variables.

World Clock
Brings numbers down to a level we can more easily comprehend.

Rx for survival
Great PBS series, with clips and other interactive material.

BBC Survival TV
Nice documentaries on global health shown in their entirety.

Johns Hopkins Free Courseware
The trend in open courseware should make us all happy!

Google trends
Not a perfect model, but an exciting idea on how to track disease outbreaks (obviously wouldn’t work in countries with low access to the web).

Healthmap
Spy on the world’s various outbreaks.

Thisispublichealth
Answers the general question “What is public health?” pretty well for a general audience.

TED
A great resource for speeches on a range of subjects. Be sure to check outy Hans Rosling’s and Bill Gates’ speeches.

Harvard World Health News
Weekly updates from various news sources on global (and domestic) health issues.

Jing
Great for demonstrations as you can capture what is going on on your computer screen. Also great for capturing Youtube videos to replay them at BYU!

NPR – Global Health
General global health news from a trusty source.

Supercourse
A repository of lectures on global health.

Facing the Future
Another list of resources (some geared towards teenagers).

Posted in Child Survival, Global Health, Global Health Topics, Links, News, Practical Advice | Tagged: , , , , , | 2 Comments »

Of Mormons and Measles

Posted by ryanlindsay on December 6, 2008

According to a recent WHO press release, the Measles Initiative is working with a 74% reduction in measles cases since 2000. The Church of Jesus Christ of Latter-Day Saints has donated at least 3 million dollars to the initiative. Members of the church have also given of their time at vaccine events in Angola, Ghana, Kenya, Madagascar, Namibia, Nigeria, Sierra Leone, Swaziland, Uganda and Zimbabwe. Presiding Bishop David H. Burton has said that “over 54,000 Church members volunteered to help organize the effort.”

Beyond monetary contributions, I would like to see more initiatives like this Measles vaccination program that tap into local congregations to mobilize communities. Could this serve as a model for future initiatives?

Posted in Global Health and Mormonism, humanitarian aid, Measles | Tagged: , , , , | 4 Comments »

New Spreadsheet on Under Five Mortality Rates (with some thoughts on disease advocacy)

Posted by ryanlindsay on June 17, 2008

Here is an excellent spreadsheet made available through some listserve discussions through the CORE group. The spreadsheet is being used by the Child Health Epidemiology Reference Group (CHERG), Partnership for Maternal, Neonatal, and Child Health (PMNCH), and the Countdown to 2015 Group. Its modeling methods are explained in the 2003 Child Survival Lancet series (another excellent resource). The 2003 version was updated recently and this is the latest version (2007).

This data is objective and comes as a great resource in the midst of a heated discussion with regards to disease advocacy and funding wars currently raging in the global health realm. The battle really was set off after Roger England questioned HIV/AIDS funding. For example, this mortality data shows HIV/AIDS as the number cause of mortality in one country, South Africa. Some diseases (especially HIV/AIDS) get more social arousal than the very unflattering diarrhea. Should funding ever be disease-specific?

Posted in Child Survival, Global Health Topics, Health Systems, HIV/AIDS, Uncategorized | Tagged: , , | 3 Comments »

Rethinking HIV/AIDS Prevention

Posted by ryanlindsay on May 22, 2008

In a recent article published in science magazine, HIV/AIDS prevention is reconsidered. I thought this was fascinating, but if you want the quick version:

  • Condom distribution works for certain demographics: particularly high risk groups such as sex workers and men who have sex with men (MSMs).
  • Abstinence is efficacious but not effective. This means that abstinence prevents transmission of HIV/AIDS, but as a prevention technique has only been shown effective at times with youth under 20. Most new cases of HIV/AIDS are from already sexually active individuals in their 20’s and 30’s.

These two aspects of HIV/AIDS prevention have their place, but in order to have a widespread epidemiological impact on heterosexual adults (the vast majority of HIV/AIDS cases in the world) two less-known, but proven prevention strategies should be considered:

  • Male circumcision – Over 45 observational, biological, and other studies from the last 20 years have shown that MC significantly reduces the risk of heterosexual HIV infection.
  • Reducing multiple sexual partnerships – Another preventive measure that has had a powerful impact and that could have even greater effect, if it were more widely and assertively promoted, is partner reduction.

The largest investments in AIDS prevention targeted to the general population are being made in interventions where the evidence for large-scale impact is uncertain.

The following graph shows that funding for proven, effective measures like promoting and provision of male circumcision is very disproportionate.

Current AIDS Funding

Source:

Malcolm Potts, Daniel T. Halperin, Douglas Kirby, Ann Swidler, Elliot Marseille, Jeffrey D. Klausner, Norman Hearst, Richard G. Wamai, James G. Kahn, and Julia Walsh. .
Science 9 May 2008: 749-750.

Posted in Global Health Topics, HIV/AIDS, Practical Advice | Tagged: , , , , , | 5 Comments »

Reconciling Moral Issues with Effective Policy by Aaron Anderson

Posted by benjamincrookston on April 8, 2008

I feel that one of the greatest complications facing public health officials today is reconciling “moral issues” with effective policy. I came to this conclusion while studying the efforts of the Thai government in its fight against HIV/AIDS.

Because of Thailand’s “vibrant” sex industry, HIV/AIDS spread rampantly in the country. Between 1989 and 1991, HIV infections rose from 3.5% to almost 22%. Infections in army conscripts rose six fold. Thailand appeared headed for a health disaster. However, thanks to the heroic, if not controversial, efforts of Thailand’s National AIDS Committee and its “100% Condom Program,” HIV was brought back under control.

Many health leaders in Thailand recognized that it would be impossible to stop people from visiting sex workers, so they sought a more pragmatic approach—they would make sex safe.

The so called “condom czar” of Thailand, Mechai Viravaidya spearheaded the effort. I watched a video of his efforts in which he explained that in order for the program to work, sex had to become less taboo. He explained that comedy had to become part of the campaign. Mr. Viravaidva impressed me with his efforts, however controversial they might have been. I was struck by images of him blowing up condoms like balloons in front of school children, handing out condoms wholesale in bars, and, most strikingly, him giving speeches in between strip shows about safe sex.

Viravaidva was primarily responsible for stopping the AIDS crisis in Thailand, however, I do not believe that such tactics would ever fly in the United States—and many other countries for that matter. Viravaidva created an innovative and successful program for his native Thailand, but replicating his tactics elsewhere probably won’t work. I think Thailand provides an excellent case study not necessarily for HIV prevention, but for demonstrating the importance of local leaders developing their own solutions for their own constituencies.

Posted in Global Health and Mormonism, Guest Bloggers, HIV/AIDS | 5 Comments »

2nd Informal Global Health Dinner: Leprosy

Posted by chads on October 25, 2007

The Utah Valley Global Health Group hosted their second informal pot-luck dinner on October 19. The theme was leprosy. A quick summary of the “take-home points” from my global-burden talk is below. Sylvia Finlayson then shared her experienced with Rising Star Outreach. About 15 people came, and delicious food ranging from spring rolls to garbanzo beans was served.

1. LEPROSY IS A CHRONIC, DEBILITATING DISEASE.

  • Leprosy is a chronic disease caused by bacterium, Mycobacterium leprae;
  • It multiplies very slowly; symptoms can take as long as 20 years to appear.
  • Leprosy is not highly infectious. It is transmitted via droplets, from the nose and mouth, during close and frequent contacts with untreated cases.

2. LEPROSY MAINLY AFFECTS THE SKIN AND NERVES.

  • Leprosy causes rashes, numbness, and enlarged tender nerves.
  • It mostly causes morbidity (suffering, disability), not mortality (death).

3. LEPROSY IS CURABLE, BUT REQUIRES 6 MONTHS TO ONE YEAR OF TREATMENT WITH 3 DIFFERENT MEDICATIONS.

  • Leprosy is a curable disease and treatment provided in the early stages averts disability;
  • With minimal training, leprosy can be easily diagnosed on clinical signs alone;
  • The WHO recommended multidrug therapy (MDT) in 1981. MDT consists of three drugs: dapsone, rifampicin and clofazimine. This drug combination kills the pathogen and cures the patient if taken for the course of 6mo-1 year.
  • Since 1995, WHO provides free MDT for all patients in the world.

4. LEPROSY ELIMINATION HAS BEEN A PUBLIC HEALTH SUCCESS, THOUGH INTENSIVE EFFORTS ARE STILL NEEDED IN 5 COUNTRIES.

  • In 1991 World Health Assembly passed a resolution to eliminate leprosy as a public health problem by the year 2000. The target was achieved on time.
  • A dramatic decrease in the global disease burden: from 5.2 million in 1985 to 805 000 in 1995 to 753 000 at the end of 1999 to 286 000 cases at the end of 2004.
  • Intensive efforts are still needed to reach the leprosy elimination target in five countries: Brazil, India, Madagascar, Mozambique, and Nepal.
  • Ensuring accessible and uninterrupted MDT services available to all patients through flexible and patient-friendly drug delivery systems will lead to elimination.

Modified from the WHO Leprosy Fact Sheet, available at http://www.who.int/mediacentre/factsheets/fs101/en/

Posted in Leprosy, Utah Valley Global Health Group | Leave a Comment »

World Tuberculosis Day

Posted by chads on March 24, 2007

Today is World Tuberculosis Day. The following was also published as an editorial in yesterday’s edition of the newspaper Deseret News.

Asian Bird Flu has received a large amount of news coverage in recent months. While news of the potential of this disease is frightening, a current global health emergency deserves at least as much attention: extremely drug-resistant tuberculosis (XDR-TB). Tuberculosis takes the lives of almost 2 million people every year, despite the fact that it can be treated for a mere $16 per person, per year. Tomorrow, March 24, is World TB Day, and action must be taken to control this deadly disease.

Tuberculosis, a bacterial disease that often affects the lungs, is almost as old as mankind. Egyptian mummies have shown signs of the disease, and, unfortunately, it has played a significant role in Utah history. Many pioneers suffered and died young from what was then known as “consumption.” Brigham Young was 14 when his mother died – from tuberculosis.
Fortunately, TB is no longer a significant public health problem in Utah. In 2005, there were only 29 cases in the entire state (4 in Utah county) – and all of those patients received the treatment that they needed. The disease is both preventable and treatable, so well-implemented programs are nearly always effective.

Because tuberculosis takes months to treat with multiple medications, treatment programs must be well-planned out, based on scientific evidence, and consistently implemented. Partially treated TB has led to a public health nightmare in developing countries. The bacteria has become resistant to one or more of the medications, and, at times, impossible to treat. This super-resistant strain is passed on to other people before it takes the life of its victim, creating a global public health emergency.

South Africa is currently dealing with an outbreak of what public health officials have called “extremely drug resistant” TB (XDR-TB). This strain of TB is the direct result of the poor TB control noted above. XDR-TB killed 52 of 53 patients in a reported outbreak — half of them within 16 days. XDR-TB is spreading in southern Africa and has been detected in at least 28 countries on 5 continents — including the U.S.

Worse, because of the deadly synergy between HIV/AIDS and TB, XDR-TB threatens to roll back progress in the fight against the AIDS pandemic.

Global problems such as the current tuberculosis crisis often leave us feeling paralyzed. It is easy to feel that these are people in far-away lands with problems too large to solve, and think that there is little that we can do. In this age of globalization with frequent international travel, however, drug-resistant tuberculosis has the potential to affect all of us. And there are definite steps that we can all take to make a difference:

1. Support legislation that will control tuberculosis in a long-term, sustained fashion. A “Global Plan to Stop TB” was recently launched (www.stoptb.org/globalplan). Contact your Congressman and senators, and urge them to support the United States’ share of support in 2008: $400 million in bilateral aid for TB efforts, and $1.4 billion for the Global Fund to Fight AIDS, TB and Malaria.

2. Get involved locally. A small group of interested citizens has recently been organized in Utah County to stay informed and involved in global health issues. We meet monthly for RESULTS (www.results.org) meetings, and have occasional social get-togethers. The next one will be on April 7. See http://www.globalhealth.wordpress.com for details, updates, and discussion.

Archbishop Desmond Tutu recently spoke of the risk of “turning back the clock to a time before TB drugs even existed.” The choice is clear: we can either take the steps necessary to save millions of lives, or live with the consequences of inaction.

Posted in Tuberculosis | Leave a Comment »

RESULTS, XDR-TB, and emergencies

Posted by chads on March 11, 2007

We had our monthly RESULTS meeting and teleconference on March 10. The thrust of the discussion was on obtaining funding for “extremely drug resistant tuberculosis”, or XDR-TB. The WHO explains:

MDR-TB (Multidrug Resistant TB) describes strains of tuberculosis that are resistant to at least the two main first-line TB drugs – isoniazid and rifampicin. XDR-TB, or Extensive Drug Resistant TB (also referred to as Extreme Drug Resistance) is MDR-TB that is also resistant to three or more of the six classes of second-line drugs.

The folks at RESULTS urge us to push our elected officials for additional funding for XDR-TB in the “Emergency Defense Supplemental”:

Please continue to urge Congress to support an emergency infusion of resources to help address the XDR-TB (extremely drug resistant TB) emergency. (The continuing resolution did not contain bilateral TB funding in it.) XDR-TB has a very high mortality rate, is especially deadly for those with HIV/AIDS, and threatens to undermine AIDS and TB treatment in southern Africa. The U.S. is also quickly facing the dangers of XDR-TB. When the president sent his Emergency Defense Supplemental request to Congress it contained monies for Avian Flu, which is a theoretical emergency. XDR TB is a REAL emergency.

I wholeheartedly agree with this plea for fundingwith a passion. Well, sorta. The need for a comprehensive response to tuberculosis is, in my mind, indisputable. And the public health crisis that barely treatable (and sometimes untreatable) XDR TB presents is unacceptable.

I have mixed feelings, however, about calling this an emergency. You see, public health officials and clinicians have known for many, many years that TB was becoming resistant to many drugs, and that it had the potential to become a public health emergency. XDR TB exists because of our failure to respond properly to TB; a failure to strengthen the health system. The WHO continues:

Resistance to anti-TB drugs in populations is a phenomenon that occurs primarily due to poorly managed TB care. Problems include incorrect drug prescribing practices by providers, poor quality drugs or erratic supply of drugs, and also patient non-adherence.

Screaming “emergency” is an effective fund-raising tool, though it more often that not comes in unpredictable spurts. It seems to me that such sporadic responses lead in the long term to corruption, dependence, and lack of preparedness for the next “emergency.” Those suffering from diseases like tuberculosis desperately need a health system that is strong, flexible, and promotes evidence-based health interventions.

So, I’ll support this Emergency Defense Supplemental funding for XDR-TB. Because something has to be done. But there has to be more of a focus on health systems strengthening.

Posted in Health Systems, RESULTS, Tuberculosis | Leave a Comment »

Recent Successes

Posted by chads on February 8, 2007

There are a number of recent global health successes that show that, yes, in fact, well-planned, coordinated global health interventions do save lives:

-According to a recent Lancet article, between 1999 and 2005, mortality owing to measles was reduced by 60%, from an estimated 873,000 deaths (uncertainty bounds 634,000-1,140,000) in 1999 to 345,000 deaths (247,000-458,000) in 2005. An article in the magazine Economist gives a good summary. See Malaria under the categories on the side bar for other posts about measles, immunization campaigns, and the LDS Church’s involvement in that campaign.

-According to Dr. Constance Bart-Plange, Programme Manager of the National Malaria Control Programme in Ghana, malaria deaths in children in the country has reduced by half between 2003 and the end of 2006. (To my knowledge, this data has not been published or subject to peer review. These preliminary results, however, are promising.)

As soon as I find some time, I will post a review on a highly recommended book that highlights a number of other global health success stories: Millions Saved.

Posted in Malaria, Measles, News | 3 Comments »