In the summer of 2016, Global Health Scholar and second year medical student Kara Abarcar travelled to Chongqing, China with Drs. Lisa V. Adams and Elizabeth Talbot to assist doctors and nurses at a a large pediatric hospital to improve the way they counsel their patients with TB. She conducted a seminar on the Teach-Back Method, incorporating the use of scripts and culturally-appropriate patient education materials. She presented the project at the Consortium of Universities for Global Health (CUGH) conference in Washington, DC in April 2017.
Given the fast pace of changing clinical practices and increasing access to medical knowledge, how should we train today’s students for tomorrow’s global health challenges? This is the central question global health educators are—or should be—asking themselves in as they develop global health programs for their students and trainees.
The Center for Health Equity’s director, Dr. Lisa V. Adams is the lead author on an article recently published in BMC Medical Education aimed at addressing this complex question. In their article, Dr. Adams and her co-authors, Dr. Agnes Binagwaho, the former Minister of Health of Rwanda, and two Dartmouth College alumni, emphasize the importance of putting international partnership and a shared drive for health equity at the center of our global health work and training programs. Learn more about their forward-thinking ideas on this topic here.
by Ashley Dunkle ’19
Ashley Dunkle is a second-year medical student and Global Health Scholar at the Geisel School of Medicine at Dartmouth. At the Ministry of Health in Greenland, she developed a report analyzing a possible national Colorectal Cancer Screening (CRCS) Program. This program was modeled after a successful CRCS Program in Alaska, a state with similar geographical, cultural, and climactic challenges as Greenland. Funded by the Dickey Center, she completed the final stage of a project started by Tuck students in which they developed an economic model to assess the costs of CRCS in Greenland under various scenarios.
“The past is fiction. The future is dream.” – Gretel Ehrlich, This Cold Heaven: Seven Seasons in Greenland
When most students think of global health summer internships, they imagine the warm African sun, sweating among saris in India, or working in crowded clinics in South America. Instead of flying closer to the equator, I packed a winter coat and heavy socks to head nearer the Arctic Circle. My home for the summer would be Nuuk, Greenland, capital of the largest island on earth. My task was to work with the Ministry of Health of Greenland to assess whether a colorectal cancer-screening program for this unique country was economically feasible.
Greenland is part of the Kingdom of Denmark. Despite gaining self-governance in 2009, they continue to receive significant economic support from Denmark. Eighty-one percent of Greenland’s landmass is covered by ice. This means that its ~57,000 inhabitants are spread amongst 17 coastal towns and 40 coastal villages that are not connected by roads. To travel between, one must take a boat, plane, or dogsled, each of which requires a specific season, appropriate weather, and resources. This leads to a unique challenge for access to healthcare. Village clinics are run by nurses and sometimes lay village health workers. To receive tertiary care, Greenlanders must travel to one of four regional hospitals, such as the national hospital in Nuuk, or to Denmark. There is no physician training in Greenland, though there is one nursing school in Nuuk. To fill in gaps in human resources for health, many of the country’s practicing doctors are consultants from Denmark who work in Greenland for a few months at a time.
These health access challenges faced by Greenlanders mean unique solutions are required to manage the burden of disease. One disease of interest is colorectal cancer (CRC). Currently, screening for CRC in Greenland is symptomatic or based on family history alone. However, early screening for CRC can save lives. In particular, a colonoscopy, the most sensitive tool, can also remove precancerous lesions at the time of screening. A colonoscopy can decrease the risk of death from CRC to less than 10%. Whereas once CRC develops, a patient has a one in two chance of survival, even with radiation and chemotherapy, which Greenlanders can only receive in Denmark.
The people of Greenland have many risk factors for colorectal cancer. Native Greenlanders often survive by hunting seal, reindeer, and the occasional polar bear (don’t worry environmentalists – this is regulated!). Some villages only get a few shipments of supplies each year to their local shops, meaning fruits and vegetables are scarce. Therefore, in addition to a high fat and meat diet, they also have a low fiber diet. Much of the meat is grilled, adding carcinogens to the food. This type of diet means the food is likely to move more slowly through the gastrointestinal tract giving greater opportunity for carcinogens to convert a cell into a pre-cancerous cell, putting them at greater risk for developing CRC. Additional risk factors for Greenlanders are cigarette smoke, alcohol use, and low exercise.
Last year, a group of first-year Tuck School of Business students were tasked with developing an economic model for what a similar screening program would cost in Greenland. The model looked at two different scenarios and two different populations. The Nuuk Scenario would fly all eligible patients to Dronning Ingrid’s Hospital, the national hospital, in Nuuk for a colonoscopy. The Regional Scenario would transport eligible patients to one of four regional hospitals or the national hospital for screening, and fly the doctors and nurses to those hospitals to conduct the screening. The models also assessed the cost difference of screening individuals aged 50-69 compared to aged 40-69, as it is hypothesized that Greenland Natives would similarly have early development of CRC like Alaskan Natives.
With an annual overall health budget of $1.8 million in Greenland, these economic models showed that CRCS via colonoscopies was not feasible. To screen 40-69 year olds via the Nuuk Scenario would cost between 7-8% of the health budget and via the Regional Scenario between 4-5% of the health budget over 11 years. One of the greatest costs was travel for patients, families, and clinicians given the expense of airfare in Greenland. Another was accommodation, which would likely require capital infrastructure investments to house the families and the patient being screened. For a country that has many healthcare challenges and other development needs, this is too high of an opportunity cost for one health program. However, CRC remains an important health issue to address in Greenland.
The conversation does not end here. What else can we design as possible solutions given the reality of this important disease? My colleagues at the Ministry of Health in Greenland are evaluating whether using a less sensitive stool test is more feasible in this scenario. This would mean more false positives and false negatives, but is superior to no screening. It would also require significant coordination and health education campaigns. Another option is to assess whether CRCS can be coopted into another cancer screening program, such as mammography, to offset some of the recurring costs. Regardless of the screening measure, it will be an important task to make sure the program reaches the unreachable—those Greenland Natives whose lifestyles may put them at greater risk but who are even less likely to access the healthcare system.
I would like to thank the Global Health Initiative and The Institute for Arctic Studies at the The John Sloan Dickey Center at Dartmouth College, and the Center for Health Equity at Geisel School of Medicine at Dartmouth, for supporting this opportunity. I would also like to extend my gratitude to the Ministry of Health in Greenland and my in-country supervisor Dr. Birgit Nicalsen for the warm welcome to Greenland and for all that I learned from you. I would also like to thank my mentor, Dr. Lisa V. Adams, for her endless support and encouragement to pursue my passion for health equity.
The Center for Health Equity has domestic and global health equity leaders providing it technical guidance and strategic direction. The Center’s board chair, Dr. Patrica Doykos DC ’86, who is currently the Director of the Bristol-Myers Squibb Foundation, is an important voice and advocate on the national stage for improving access to care among traditionally underserved populations in the US and abroad. Read her latest commentary entitled “Striving for Equity in Access to and Use Of Specialty Care” in which she highlights how it will take more than increased funding and promotes creating a health equity mindset to bring about the sector-wide changes needed to address this complex and compelling issue.
About Dr. Patricia Doykos:
Patricia Mae Doykos is director of the Bristol-Myers Squibb Foundation whose mission is to promote health equity and improve the health outcomes of populations disproportionately affected by serious diseases and conditions. Patricia works on health strategy and evaluation for the Foundation overall and leads the flagship philanthropic program, Together on Diabetes®: Communities Uniting to Meet America’s Diabetes Challenge. This program was launched in November 2010 and has provided over $53 million in funding to 26 grantees working in over 60 communities across the country to advance health equity for adults living with type 2 diabetes by strengthening patient self-management education, community-based supportive services and broad-based community organizing and mobilization. Patricia joined the Bristol-Myers Squibb Foundation in 2002 after working for 5 years on the business side at Bristol-Myers Squibb in International Corporate Affairs. In addition to the Together on Diabetes program, she has developed and led U.S. and international grant making and partnership programs for women’s health, global HIV/AIDS, cancer and serious mental illnesses. Outside of her work at Bristol-Myers Squib, Patricia serves on the advisory board for a few health and research organizations. Patricia received her BA as a double major in Government and German Studies from Dartmouth College, MA in German Language & Literature from the University of Virginia and PhD in German Studies and Cultural Studies from New York University.
by Mengyi (Zed) Zha
I chose to go to Muhimbili National Hospital for an elective after Match Day and before graduation. I figured this would be a good time to travel as I would have the energy to immerse myself in a new culture. Having grown up and gone through part of my medical training in a resource constrained country, the living condition and lack of resources in the public hospital did not come as a complete shock to me. But how much the patients endure and the challenges to patient advocacy really surprised me.
The teaching at Muhimbili National Hospital is great. I felt warmly welcomed by both the faculty and students. The 5th year students took me in as a member of their group right away and we became really good friends. (They even gave me Swahili lessons in exchange of me teaching them Chinese.) I saw so many diseases that I would never have the chance to see in the US. I learned to care for end stage HIV patients, complicated TB and malaria patients in a resource constrained environment. I also spent two weeks in Dermatology, during which I saw many skin manifestations of infectious diseases such as HIV and TB. As part of my career I hope to take care of HIV and TB patients, and this experience has given me a glimpse of what that might look like. I would encourage anyone who is interested in practicing in a low-income setting to take part in this elective. At the same time, Dar es Salaam is a very livable city (despite the intense heat and humidity from being near the equator), and Tanzania is just a beautiful country. I hope I can come back after learning more Swahili.
There was an occasion, however, when my intern and I felt alone and helpless in the fight for the wellbeing of a patient: On a particular national holiday, my intern and I were the only ones from the medical team on the infectious disease ward taking care of over 15 patients, a few of whom were critically ill. This included a patient with stage IV AIDS and PCP lung infection, for whom I had been pushing to transfer to the ICU for days. I put the patient on 15L of O2 the previous day so that his oxygen saturation was over 90 percent. On this day when I showed up in the morning, the patient’s oxygen tank was empty because it had run out overnight and there was nobody to change it, leaving his oxygen saturation very low. After transferring and changing the tank myself, the patient was still only saturating in the low 80s. My efforts to transfer the patient to the ICU continued to fail due to his terminal status. The patient deteriorated throughout the morning and arrested during the lunch hour (a busy time when family typically visits). Our resuscitation efforts were challenging due to lack of nursing staff; several times I had to stop chest compression to search for medications and proper devices. The patient passed away. The family broke down crying, and so did I. It was through such emotional turmoil that I have developed a heart for the patients and their families.
This elective is generously supported by a grant from the Hanover Rotary Club.
By Edom Wessenyeleh (DC ‘17) and Olivia Rosen (DC ‘17)
Five faculty from Dartmouth’s Geisel School of Medicine traveled to China earlier this summer to share their expertise with medical professionals from Xi’an Medical University at The International Summit Forum on Higher Medical Education in General Practice. The five-day conference, aimed at advancing the development and delivery of family medicine at Xi’an Medical University (XMU), focused on the importance of family medicine and the integration of primary care, hospital care, and community-based care. This extraordinary opportunity recognizes Geisel’s strength as a leader in medical education and primary care training and establishes a platform for further knowledge sharing.
“Xi’an Medical University was thrilled to have the chance to work with Geisel School of Medicine and with Dartmouth-Hitchcock Medical Center to expand their family practice section,” says James McGuire, PhD, FCCP Senior lecturer and Pall Life Sciences Senior Consultant at the VA Regional Medical Center in White River Junction, VT. McGuire was contacted by Manling Liu, MD, of XMU to head the organization and planning of an international conference centered on topics of critical care and family practice. Lui and McGuire have known each other for years through their affiliation with the American Association for Respiratory Care—Lui is a past international fellow, and McGuire has been a consultant at XMU.
Accompanying McGuire to China, were Steve Liu, MD, an associate professor of Community and Family Medicine; Lisa V. Adams, (Med ’90), an assistant professor of medicine and associate dean for global health; Catherine Pipas, MD, (MPH ’11), a professor of community and family medicine and assistant dean for medical education; and Kenneth Rudd, MD, MPH, an assistant professor of community and family medicine.
On supporting XMU in their primary care mission, Pipas says it was an “opportunity for us to learn and to teach and advance the health of our broadest population. If we consider our Dartmouth vision for the healthiest population broadly, then this population extends to our global partners.”
In addition to lectures and interactive seminars, the Geisel team also visited affiliated hospitals and health centers around Xi’an to observe local primary care systems and share experiences. Liu was particularly affected by this part of the visit, saying he was “impressed by the involvement of families in the care for hospitalized patients—the families are expected to bring food for patients who are in the hospital.” He adds, “We also witnessed family members providing physical therapy for patients. Although this stems from a lack of resources in China, compared to the US, allowing family members to participate in the care for hospitalized patients is probably something that we should encourage more of here.”
The Geisel delegation has high hopes for a relationship between the two centers. “We hope that this visit leads to an ongoing collaboration between the two institutions in the future—one possibility, is that Dartmouth students and faculty who are interested in global health could have the opportunity to travel to XMU to learn more about their health care system,” Liu says. “We could also host members of Xi’an in the future so that they could get a better understanding of health care in the US.” Overall, the teams at both institutions are interested in exploring the potential for collaboration, learning, and exchange between Dartmouth and XMU.
Although they are far apart, the two schools do have something in common—neither is located within the main knowledge centers of their respective countries, yet both have prospered. But a difference is that Dartmouth has a well-established reputation for excellence, while XMU is gradually building its reputation independent of the megacities of Shanghai and Beijing that receive the majority of the attention and financial resources.
There are other commonalities, too. Liu says he is, “surprised by the similarities and challenges we both face in paying for health care, increasing access to care, and attempting to improve outcomes of care.”
Similar to health care in the US, XMU is dealing with the realities of too many patients seeking specialists for their care and increasing health care costs. The school plans to establish a new center of primary care excellence in Western China, which could prove to be an exciting partner for Geisel.
As this visit to China illustrates, it is clear that Geisel School of Medicine is being sought after for its expertise in primary care and global health.
Our new video highlights the important mission and the impact of Dartmouth’s Center for Health Equity.
By Larry Di Giovanni
Note: This is the first of a four-part series examining the Geisel School of Medicine’s long-standing work in primary care with American Indian and Alaska Native communities. Read parts two, three, and four for more.
From New England to Alaska, the impact of Dartmouth’s Geisel School of Medicine within American Indian and Alaskan Native populations, rural and urban, is strong and expanding.
The reasons are many: compassionate students with a desire to serve the underserved; new opportunities for clinical teaching in family medicine, which means more mentors and student experiences in Native American communities; primary care physicians who step forward to serve as role models; and diverse primary care clerkships and residencies that reach into American Indian/Alaskan Native country. In addition, a Memorandum of Understanding with the Indian Health Service and Dartmouth, signed in 2012, is strengthening opportunities for collaboration.
Just as important has been Dartmouth College’s unwavering, long-standing commitment. Since 1769 as part of its founding charter, Dartmouth has been engaged in the education of Native Americans. Over the past few decades, that commitment has created a range of medical education experiences that introduce students to these communities and their health care needs, ultimately leading to improved health care delivery for Native Americans.
Just one such “incubator” program started by Shawn O’Leary, Geisel’s director of multicultural affairs, has grown in impact and importance. Each March since 2010, a new group of first-year medical students has accompanied O’Leary to northern Minnesota for the Geisel-Indian Health Service alternative spring break serving five bands of the Ojibwe (Chippewa) tribe.
By Susan Green
When Steve Bensen (’90) talks about the two months he spent in Rwanda earlier this year, you can hear the optimism in his voice. Exhilarated by his first foray into global health, he wants to help others have a similar experience.
Bensen, an associate professor of medicine at Dartmouth’s Geisel School of Medicine and physician at Dartmouth-Hitchcock Medical Center, who specializes in gastroenterology and hematology, is the first gastroenterologist to participate in the Human Resources for Health (HRH) program. A seven-year partnership between the Rwandan Ministry of Health, the Clinton Foundation, and several U.S. medical schools, including Geisel, HRH is committed to rebuilding the medical education and health-care systems in Rwanda.
“I tried for a number of years to do something like this and investigated different avenues,” Bensen says. “But it’s difficult for a gastroenterologist because we are dependent on technology when offering our skills.”
Although there is significant gastrointestinal (GI) disease in Rwanda, physicians lack both the equipment and training to provide specialized care. Armed with hundreds of donated endoscopic devices—biopsy forceps, snares, balloon dilators, PEG kits, and esophageal band ligators—Bensen’s goals were to teach physicians, residents, and interns to perform simple GI procedures and to show hospital managers the importance of providing these devices. “There’s an amazing amount of good to be done with fairly simple instruments,” he says.
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.)
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.