Saturday, December 15, 2012

Eva Tovar Hirashima
Harvard Affiliated Emergency Medicine Residency
Mexico City, Mexico
Sexual Health of Migrant Women in Transit Through Mexico: What do they have to say about HIV/AIDS and Unwanted Pregnancy”

It’s the end of the road, at least for this trip. I didn’t get to do all the interviews that I thought I would but I was lucky enough to get a glimpse of a world that up until now was unscathed territory for me. The gap of women that I talked about on the prior blog was still there and seemed unfathomable throughout the trip but the world that I was introduced to taught me a new language, and led me to understand a new set of priorities and acquire a new sense of urgency. The irony of it is that what seemed novel to me is an ancient request: shelter, food and water, and basic healthcare.

Don Martin, a migrant himself in the 80s, decided to provide the migrants who travel on the train on their way up north with humanitarian aid by throwing bags of food, water and clothes to the clandestine passengers of the train.

He has been doing it for the last 12 years. His family helps him, including his 4 year old grand-son.

Sara, a migrant from Honduras, who I met in a shelter in Mexico City called Tochan, is helping Don Martin´s daughter pack bread that will later be placed in a bag with water and fruit. The bags will be thrown to the people who travel on the train.

Alex, a migrant himself, is choosing fruit that will be placed in the bags

We managed to get a donation of condoms and oral rehydration therapy that will be placed in the bags

Regarding health, Sara a migrant herself, and I held a workshop of HIV with the other residents of Tochan, the migrant shelter in Mexico City.
After the workshop a few of the attendees agreed on going to a clinic called "Clinica Condesa" in Mexico City, to get tested. The test is free and counseling is available regardless of migratory status.

Another task that I set myself to do was to strengthen inter-institutional collaboration among the different actors.

 In the photo, Gabriela, the coordinator of the shelter in Mexico City -Tochan- is meeting Dr. Florentino from the "Clínica Condesa". The clinic has an impressive sexual violence program, where PEP (post-exposure prophylaxis) and other STD management, birth control and OBGYN follow up is available for free. 

Unfortunately the clinic is exceptional in Mexico, in fact I was told that according to the Mexican norm, PEP can only be provided to a victim who was sexually assaulted by 2 or more individuals.

Sara receiving a donation of condoms from the “Clinica Condesa” that will be placed inside Don Martin’s bags.

As expected the health needs of the migrants in transit are diverse: diarrhea, URI, conjunctivitis, skin rashes, frost bite (when travelling thorough the center of Mexico), dehydration and heat stroke (when travelling through the desert) were the more frequent complaints. Unfortunately amputations and trauma after falling off the train were also prevalent. It was no surprise to hear, that during their journey migrants are reluctant to search for medical assistance either because of fear of deportation or because they were denied care in the public health care clinics in previous attempts. Based on the former, Doctors without Borders has established clinics in 3 shelters: Arriaga (Chiapas), Ixtepec (Oaxaca) and Huehuetoca (Edo. De Mexico). Medical assistance along the train tracks is also provided by the government funded group called “grupo beta”, however the demand for care seems to overwhelm the capacity of the existing resources.  

A few of the migrants with active health care needs I encountered in Tochan were:

He got shot in the train and required a splint and crutches for a few weeks.
He fell down from the train and suffered a clavicular fracture. Doctors without Borders transferred him to a local hospital where he got surgery and then transferred him to Tochan where he’s awaiting his recovery.  

The need of a network of local physicians that can help out Gabriela regarding the healthcare needs of the migrants led me to organize a meeting. 

The turn-out was higher than expected, among the participants there were ID, renal, medicine and pediatricians.

Sara talked about the hardships they encounter during their journey and enumerated their health needs during the journey such as: NSAIDs, sun block, mosquito repellent, condoms, dressings, hydrogen peroxide, iodine, among others.

They listened, and at the end the conclusion was that once a month they were going to volunteer a day to provide the migrants and the community (to increase acceptance of the shelter among neighbors) with free health care; a facebook page, where Gabriela and other first contact providers, could get assistance and medical counseling would be created; and workshops regarding HIV as well as other medical topics would be organized.

At the end, I was reminded of Don Martin's words, and repeated to myself "No, they're not invisible".

Thursday, November 29, 2012

“Sexual Health of Migrant Women in Transit Through Mexico: What do they have to say about HIV/AIDS and Unwanted Pregnancy”

Eva Tovar Hirashima
Harvard Affiliated Emergency Medicine Residency
Mexico City, Mexico

I’ve been here for almost 3 weeks. On the second day of the trip, I was surprised to find out that one of the shelters I was intended to work in, located close to Mexico City in a town called Huehuetoca, had to be closed down 3 days before my arrival for security reasons. A shooting happened inside the shelter, it’s still unclear if it was the Maras or the Zetas, I’m an amateur to the violence and cannot understand the difference, but a bullet is a bullet regardless its origin.

To set the context, Mexico is a country of origin, transit and destination for migrants. In 2010, according to estimates derived from Mexico’s National Migration System 140,000 Central Americans entered Mexico without documents. Migrants face a variety of human rights violations and are at risk for extortion, abduction, rape, murder and forced recruitment into criminal gangs. Based on the official numbers, women constitute around 15-20%, however an interesting piece of unofficial information that I’ve come across during this trip is that the percentage of women, decreases the further north you travel; it’s unclear why they disappear, how it happens or where they go. Regardless or as a reflection of the former, women are especially vulnerable facing serious risk of abuse and sexual violence by criminals, other migrants and corrupt public officials. Accurate figures regarding the magnitude of sexual violence in migrant women are inexistent nonetheless human right organizations estimate that 6 in 10 women and girls experience sexual violence during their journey. The long term goal of the project is to figure out a way to provide victims of sexual violence accessible, appropriate and impartial medical management. I’m currently on the initial phases, and the objective of this trip is to gather qualitative data regarding the problem by interviewing migrant women in shelters.

Convenience store in Huehuetoca called "the border" starts before you know it!

I haven´t had much luck finding women, the initial closure of the shelter and the increase in security checks have been an obstacle for the interviews. I spent some time visiting the parish in Huehuetoca, where I had to relinquish my Harvard student ID, in order to speak with the priest about the project. The reason for the visit was because the shelter (as most migrant shelters in Mexico) is run by the Catholic Church. The first thing I was told was “No cameras, no photos of migrants, it’s too dangerous”.  After the necessary introductions, I found myself talking about female/male condoms, post-exposure prophylaxis (PEP) etc., and I have to admit that listening to my voice as it echoed in the office of high ceilings made me wonder if what I was saying could be interpreted as sacrilegious. But he and his assistant listened, and when it came to their turn to speak, the panoply of necessities, intermingled with specific anecdotes to stress their point, came pouring out: strengthening security measures, legal assistance, medical care, prenatal care (any type of medical care!) were but a few of their requests. I reemphasized that I was there to gather qualitative data. They understood and now I’m waiting for the approval of the bishop to gain entrance to the shelter.  
Serendipity led me to an exceptional man, who is not a priest, or a doctor, or a lawyer. He’s a simple man who in the 80s also became a migrant. He lived in the US and after saving enough money to build his house, returned to Mexico, his home-country. His town is close to the train tracks. The train, also known as “La Bestia” or “The Beast”, is one of the main modes of transportation because it’s free, and the railroad crosses the country from south to north. Migrants travel clandestinely on the train roofs. The journey can be tough, the lack of food and the changes in weather (cold in the mountainous regions, hot and humid in the tropics) are but two of the challenges they face in a daily basis. This exceptional man, that will remain nameless for now, understood this and for the last 12 years has been distributing plastic bags filled with bottles of water, oranges and bread. I witnessed his wife, daughters and grandsons prepping the bags, running to the tracks, signaling to let the rest know which train cars have people, and finally handing the bags to the migrants or throwing the bags into the train because most of the time the train will not stop and the bags need to reach their destination. At the end of that day, the exceptional man, smiled with his toothless smile and told me with pride that the cause of his missing teeth was not diabetes (which he has been diagnosed for a while but hasn´t received care for the last 2 years because of lack of money) but the multiple falls he’s suffered chasing “La Bestia”.

"La Bestia" approaches!

Distribution of food and water along the tracks

The lack of women to interview feels eerie but it has made me diversify.  I’ve been in contact with a small shelter in Mexico city (it only has 10 beds) and now I’m working on strengthening the alliances of it with a clinic in Mexico city which provides free care (including PPE for HIV when applicable) to victims of sexual violence. The clinic has agreed to manage migrants regardless of their migratory status in cases of sexual assault as long as they’re able to go to the clinic. 

Migrant shelter in Mexico City

Street performance organized by the shelter to raise awareness regarding gender violence

In addition, I’m working on establishing a network of local physicians that are available to the shelter for medical advice. Some days, things seem slow and unattainable, and I’m inclined to think that migrants are unreachable but I remember the words I just heard a few days ago: “People like to call them invisible, but I don’t think it’s accurate, I see them every day on the tracks.”

Tuesday, November 27, 2012

Tiffany Chao, MD, MPH  General Surgery Resident
  Massachusetts General Hospital
  Paul Farmer Global Surgery Research Fellow
  Program in Global Surgery and Social Change  Harvard Medical School / Children's Hospital Boston
JFK Medical Center
Monrovia, Liberia


My time in Liberia has come to an end and I am just returning to Boston from 5 weeks at JFK Hospital in Monrovia.

JFK Memorial Medical Center

Though time moved quite slowly there, I was able to accomplish my goal, which was to further develop the relationship between the JFK Surgical Department with Harvard Medical School's Program in Global Surgery and Social Change (PGSSC).  We accomplished this through a combination of educational initiatives, research infrastructure development, and clinical work.

From an educational perspective, I gave plenty of lectures to the medical students about all sorts of surgical topics.  I was even at JFK when the Department of Surgery was giving hospital-wide Grand Rounds, and, along with two of their surgical house officers, presented gastric ulcer disease:

Department of Surgery giving JFK Grand Rounds

From a clinical perspective, I was joined by my PGSSC colleague, clinical fellow Dr. Rowan Gillies, for a week at the end of my stay.  I was fortunate to join him for a couple of operations while the other local surgical house officers were busy.  Rowan, a Plastic Surgeon, has plenty of experience having been a former International Council President of the Nobel-Prize Winning Médecins Sans Frontières, so it was a real pleasure to get to work with him clinically!

Operating with Dr. Rowan Gillies

I made terrific friends out of the colleagues I met in Liberia.  In fact, one of the scrub nurses had actually worked with me before -- in 2008, when I was a medical student visiting Liberia from Mount Sinai Medical School!  In addition, there was even a scrub tech wearing scrubs that he had received from from Mount Sinai surgeons!  It is a small world.

 OR staff

While it was bittersweet to say farewell to JFK Hospital and Liberia, I look forward to returning -- hopefully, this spring!  We have research collaborations that are ongoing, and I plan to return with another one of the PGSSC clinical fellows as well.  I imagine that the cold New England winter will have me dreaming of the Liberian beaches!

Thursday, November 1, 2012

Surgical Infrastructure and Operative Capacity in Liberia

Tiffany Chao, MD, MPH  General Surgery Resident
  Massachusetts General Hospital
  Paul Farmer Global Surgery Research Fellow
  Program in Global Surgery and Social Change  Harvard Medical School / Children's Hospital Boston
JFK Medical Center
Monrovia, Liberia
Ever since I visited Liberia in 2008 on a surgical trip with my medical school, I have wanted to return to this country.  Liberia, a small West African nation approximately the size of the US state of Virginia with a population of 3.5 million, at once demonstrates real health care capacity needs and the potential for considerable progress. A post-conflict nation recovering from a devastating 14-year civil war (1989–2003), Liberia is in the midst of critical period of stabilization.  Studies have begun to address the longstanding dearth of data regarding Liberian surgical capacity, and  the burden of specific disease entities and evaluation of particular interventions through outcomes monitoring are also of particular interest.

This year, I had the opportunity to work with Harvard Medical School's Program in Global Surgery and Social Change (PGSSC) as a research fellow, and I was extremely lucky that our program works in Liberia in addition to Partners in Health sites in Haiti and Rwanda.  Because of this, I have been able to come to Liberia for five weeks in October and November in order to teach medical students, contribute to clinical care, and develop research projects in conjunction with the local surgeons at JFK Medical Center, which is the country's only tertiary care hospital.
Here is a photo of me teaching medical students before rounds. My iPad has proven to be quite handy for this!

The current research project that I am working on with the entire surgical department involves developing a fundamental knowledge base about surgical demographics and operative capacity through a comprehensive operative log review and analysis at JFK Medical Center during 2009-2012. This data will guide the development of surgical capacity at the primary medical institution in the country in an epidemiologically-based and patient-centered way that can hopefully be replicated throughout the country. Once established, this knowledgebase can be used to focus direction of limited resources to provide high-quality care, improve efficiency and guide development of residency programs in the most crucial clinical areas.  

I have already been in this country for two weeks, and it is remarkable how much the infrastructure has advanced since 2008.  Back then, we had blackouts nearly every day and were often forced to operate in the dark with headlights.  Today, that would be unlikely, and the only time we ever lost power was in our dorms, at night, during a particularly bad storm.  That is progress!  
Of course, there are still significant resource limitations here, as in all developing countries.  

Here is a picture of a "wheelchair."

In particular, surgical capacity in Liberia is limited by human resources--in addition to the extremely limited numbers of physicians in this country, there are only four fully-trained surgeons working in this entire country, and only two of them operate full-time.  The good news is that there are plenty of medical students in the pipeline.  As you can imagine, I have been trying to encourage the medical students to go into the field of surgery!

Tuesday, September 25, 2012

Trends in HIV care in southern India and implications for future practice

Brian Chan
ID fellow, BWH/MGH

My time in Chennai is starting to draw to a close. Since I first posted, I have seen a variety of interesting cases, toured the state-of-the-art lab facilities, sat in on pre-ART and post-ART counseling sessions, gave a talk on HIV-associated neurocognitive disorders, and began hunkering down on some research proposals for the coming year and beyond.

First, the clinical stuff. I saw another interesting rash, affecting a middle-aged gentleman. CD4 count in the 200s. He had an itchy, nodular rash on his body, most prominent on his forearms, shins and dorsum of feet, posterior neck. He scratches them like crazy. Some of these feel papular, some of these feel nodular. He has some pus that he can express from these nodules (as seen in the photo of his L forearm). We had concern for nodular scabies, but we didn’t see anything under a microscope. Plan to empirically treat this for scabies anyway.

Have also had a great case of a man with a low CD4 count recently started on ART who had change in mental status. In the CSF, he was found to have cryptococcal ag +, + MTB PCR, and + HSV PCR! Not to mention VDRL + from the serum (though neg from the CSF). So potentially 3 infections in the CSF, not counting HIV itself! He is doing well (mental status has improved a lot) on high-dose fluconazole for the crypto (he bumped his creatinine to amphotericin), acyclovir for the HSV, anti-TB drugs, and continued ART. Also treating him for syphilis. There’s a question of whether he had an IRIS that unmasked these infections, but so far he has not needed any steroids.

Some pretty bad molluscum contagiosum:

This guy had a bullous lesion on his chest that popped, drained, and now remains open, but is now getting smaller on TB therapy.

Plenty more beyond these—CMV retinitis, lots of crypto meningitis, TB of the abdomen presenting as bowel obstruction, stavudine-induced pancreatitis.

Aside from these conditions that we don’t tend to see so commonly in the US, it’s become evident that chronic, non-communicable diseases are highly prevalent and morbid in this population. India is becoming wealthier, and the age of YRG CARE’s patients seems to be creeping higher (I saw a lot of folks in their 40s, 50s, and 60s). As a result, my research with YRG CARE going forward will focus on these chronic, non-infectious co-morbidities. We plan to start off with a relatively simple study looking at changing characteristics of patients presenting to care (are people presenting at higher or lower CD4 counts, are they presenting with OIs, are they presenting at an older age, etc.). We are also going to prepare a clinical series of patients hospitalized at YRG CARE with stroke. Next, we’ll get some prevalence data on comorbid diabetes, hypertension, and CAD/MI on the YRG CARE population. Ultimately, I also think that studying the prevalence -- and treatment – of depression in HIV+ patients will also be very fruitful, and I plan to delve into this in more depth after returning to Boston, and on my return trip to Chennai, which will be sometime in January or February.
Many thanks to the Partners COE for funding this trip and allowing me to gain this experience.

Monday, September 10, 2012

Trends in HIV care in southern India and implications for future practice

Brian Chan
ID fellow, BWH/MGH

During the academic year 2012-2013, I (under the mentorship of Dr. Ken Mayer, BIDMC Infectious Disease / Fenway Health) will be collaborating with Dr. N. Kumarasamy and others at YRG CARE. YRG CARE is a non-governmental organization based in Chennai, India that provides HIV information, education, voluntary HIV counseling and testing (VCT), and care and support including Anti-Retroviral Therapy to those infected with HIV. Chennai is a city of over 6 million people in the state of Tamil Nadu; it carries one of the highest burdens of HIV in the country. Clinicians connected with YRG CARE made the first diagnosis of HIV in India in the 1990s. Since 1996, YRG CARE has provided care for over 17,000 HIV-positive individuals.

The goal of my approximately 3.5 week long trip to Chennai is to establish a relationship with Dr. Kumarasamy and others at YRG CARE, gain clinical experience at the YRG CARE clinic and inpatient facility, begin conducting a study based on the YRG CARE Natural History clinical database, and lay the groundwork for future studies to be undertaken later this year.

I’ve been here for about 4 days now, and I am already incredibly impressed by the whole YRG CARE organization. There are usually 4 clinicians giving outpatient care everyday from Monday through Saturday, and there is a small inpatient unit as well. Each clinician sees around 20 or so patients per day—busy, but the clinicians manage while doing a remarkably thorough job. YRG CARE is also a site for several clinical trials (for example, it was a site for the  landmark HPTN 052 study which showed that early ART prevented transmission among sero-discordant couples).

In the clinic and the inpatient wards, I’ve already seen a huge variety of patients—ranging from small children to the elderly, and patients with CD4 counts in the single digits to “elite controllers.” A couple of days ago, we had a young man with a CD4 count in the 20s being treated for PCP and pulmonary TB, who had a few weeks’ of a scaly rash on his left shin and foot. He had had this rash before, and it had apparently gone away with an injection. This seemed to us to be a fungal rash vs. psoriasis (I ran this by a dermatologist back home, who favors psoriasis).

We also saw an older gentleman with a CD4 count in the 50s, with months of slowly enlarging cervical lymph nodes. Probable TB lymphadenitis. But they did feel a bit on the firm side for TB, so could be possible malignancy. He is going to undergo a FNA as a first step in diagnosis.

Monday, August 27, 2012

Measuring Head Trauma Outcomes and Neurosurgical Capacity Building in Mbarara, Uganda

Patrick Codd, M.D.
Neurosurgery, MGH

Site: Mbarara University of Science and Technology, Mbarara, Uganda

As part of an ongoing effort to build a collaboration between the neurosurgery departments of MGH and MUST, I have been working with Dr. David Kitya to improve neurosurgical capabilities within this hospital.  Dr. Kitya was recently hired to assist with care of the extrodinary number of head trauma patients witnessed by the MUST hospital as the result of bodaboda (motorcycle) and car accidents, as well as care for the general neurosurgical needs of the community.  He has been exceptionally welcoming, and we have worked for the last week on several issues.

First, the neurosurgical drill (including cranial perforator and craniotome) generously donated by Stryker and deliered to MUST by several of my resident colleagues over prior visits, appears to have broken.  This has left Dr. Kitya using Gigli saws and Hudson brace perforators to perform craniotomies, with variable success.  I spent last week trouble shooting these devices, and we determined that several of the components may have been improperly cleaned resulting in electrical shorts and instrument failure.  We have devised a plan to 1.  return the broken components to the US for repairs prior to them being delivered back to MUST, and 2.  to create simplified and readily available instructions for proper cleaning and handling procedures to help prevent the issue in the future. 

Also, we have been working to fine tune the record keeping for head trauma patients presenting to the hospital in order to quantify not only patient outcomes, but to objectively track the benefit or lack therof in introducing the electrical surgical drill and other instrumentation into the the equipment list of this hospital.  Dr. Juliet, an extremely capable senior surgical resident at MUST has taken on the task to tracking these data and we will continue to support her work.

It is anticipated that this coming week will bring several operative cases that have been awaiting the completion of the new operating theaters.  Updates and pictures will be pending.

Friday, August 10, 2012

Measuring “illness” and treatment-seeking behavior in rural India: a qualitative study of malarial infection among marginalized populations, Gadchiroli, Maharashtra, India.

Radhika Sundararajan MD PhD
Harvard-Affiliated Emergency Medicine Residency

My data collection in Gadchiroli District has come to an end for this year, and am now heading back to Boston to start the data analysis phase. It was quite an experience living and working in rural India during the monsoon season, battling mosquitoes, avoiding poisonous snakes, learning to have patience for power cuts, slow (and often non-working internet), phone service outages and learning to tolerate the overall dampness of everything I owned. Besides the innumerable lessons that came with each day of qualitative research, rounding in the rural hospital, and shadowing the physicians in outpatient clinic, I even learned that mold can actually grow on the outside of a suitcase and that DEET does not appear to deter the robust mosquitoes in this area. I will miss the lush greenery of forests, and rice paddies dotted with bright sarees and livestock. I am, however, looking forward to sleeping in my warm, dry bed. 

Our qualitative study of malaria infection and treatment-seeking practices among rural tribal communities led us to speak with over 80 people in this area, learning more about how malaria is conceptualized, knowledge is created, and disease treated (or not treated), from perspective of patients, health providers, community health workers and district health officials. This is a rather large sample for a qualitative study! I was privileged to carry out this important work in collaboration with the spectacular NGO, SEARCH (, through which a tribal hospital and rural health outpatient clinics have been established, as well as a mobile medical unit which visits remote villages on a weekly basis to provide medical care. I look forward to returning to Gadchiroli next year to carry out the next phase of our project, which will be developed based on the results from this year's data collection. I have been assured that the climate is much more dry outside of the monsoon!

Monday, July 23, 2012

Measuring “illness” and treatment-seeking behavior in rural India: a qualitative study of malarial infection among marginalized populations, Gadchiroli, Maharashtra, India.

Radhika Sundararajan MD PhD
Harvard-Affiliated Emergency Medicine Residency Program

Over half of my time here collecting qualitative data has passed, and
we are finishing up our interviews this week. Spending time in this
area has given me an appreciation for the realities of rural life in
India (and a healthy appreciation for bug spray!). The villages here
are quite remote, separated by tracts of thick forest. These areas are
dotted with Primary Health Centers, where medical officers and nurses
are staffed. However, these centers are supposed to serve villages
located over 20 kilometers away, and the vast majority of villagers do
not own a motorized vehicle. Transport is accomplished by walking,
bicycle, hitching a ride on a bullock cart, or by public bus (which
I’m told exists, but I’ve never seen). This is the same hurdle faced
by community health workers, trained by the government to do active
surveillance for fever and test for malaria. These workers are meant
to monitor a population of 3,000 people on a weekly basis, but when
villages are as small as 60-75 people, this responsibility can
translate into a heavy travel burden, particularly in the absence of
mechanized transportation. The community health workers told me they
often walk between villages, which is actually quite dangerous as the
forests are full of poisonous snakes. In fact, there have been 12
poisonous snakes found in my camp in the past 16 days. Not
surprisingly, snake bite is a common (and potentially fatal) health
hazard in this region.

The landscape here is really serene and beautiful, with thick green
forest dotted with small villages and rice paddies. It’s the most
peaceful part of India I’ve ever seen.

Friday, July 13, 2012

Radhika Sundararajan MD PhD

Harvard Affiliated Emergency Medicine Residency Program

Measuring “illness” and treatment-seeking behavior in rural India: a qualitative study of malarial infection among marginalized populations, Gadchiroli, Maharashtra, India.

Malarial infection is a major public health concern, thought to cause approximately 3000 deaths worldwide per day, with the severest consequences of morbidity and mortality bourn by the world’s poor and most vulnerable populations. Within India, the World Health Organization reported 1.5 million confirmed cases of malaria in 2009, with the highest number of malarial deaths outside of the African continent. A recent Lancet study estimating approximately 200,000 deaths annually from malaria, with the overwhelming majority of these deaths occurring in rural areas (>90%) and not associated with a formal healthcare facility. WHO South-East Asia Regional Office (SEARO) report in 2007 notes the incidence of malaria is almost doubled in rural areas, as compared to urban settings (135 versus 73/100,000, respectively).

My project is aimed at developing a better understanding of the persistently high rates of Plasmodium falciparum malaria among tribal populations in Gadchiroli District, in Eastern Maharashtra. This district had over 13,000 cases of confirmed malaria in 2011 (approximately 70% are P falciparum). The region is rural and heavily forested, with a population composed of nearly 50% tribal members. Tribal people represent approximately 8% of the total population, and represent over 17% of the rural poor nationally. They are considered members of "scheduled castes" or "scheduled tribes", and have been described by the National Vector Bourne Disease Control Programme (NVBDCP) as "groups of people with social, cultural, economic, and/or political traditions and institutions distinct from the mainstream or dominant society that disadvantage them in the development process". My current research will gather qualitative data from groups that represent various factors involved in the use of, delivery of, and compliance with adequate malaria prophylaxis and treatment. Data is being gathered through focus group discussions (FDGs) as well as interviews with a few key informants. This research is being conducted in a partnership with the NGO SEARCH (

I completed 10 days in the field, and have travelled throughout the district to visit tribal villages and primary health centers (PHC), staffed by allopathic practitioners. We have done 4 FDGs with tribal men and women, as well as one with Auxiliary Nurses and Midwives (ANM) and one with Multi Purpose Workers (MPW). The latter two groups are government-trained community health workers, whose task is to do active surveillance in villages for fever cases, POC testing (with rapid diagnostic kits), take blood smear for definitive testing, and begin presumptive treatment while blood smear results are pending. I've also done interviews with medical officers in charge of the primary health centers, district health officer and district malaria officer (appointed by the NVBDCP). All these lines of data are aimed towards developing better understanding the barriers to adequate malaria prophylaxis, screening and treatment among tribal communities in Gadchiroli. Most interviews are being done in Gondi (the local tribal language) or Marathi, with the assistance of a translator. So far, we have learned that - at the village level - fever cases are often self-referred to a traditional healer (Pujari) within the village. When herbal remedies are not effective for fever, the villagers often go to a nearby town where there is a "Bengali Doctor" (not an allopathic practitioner, actually referred to as "quack doctors" by medical officers in India) for "injection and saline" treatment. These treatments are sought primarily because they appear to relieve the symptoms of fever, but obviously does not treat the underlying problem of potential malaria. While tribal people appear to have basic knowledge about malaria as a potentially severe illness, this knowledge does not translate to practice. While distance is often a limiting factor in visiting PHCs (hence the important role of ANM and MPW in rural health), cost is not as much of a factor. The PHC provides services for only 2 Rupees (about 4 cents) and all medications are provided free of charge. In contrast, the cost of treatment by a Pujari or Bengali Doctor is on the order to 100-200 Rupees.

We have more focus groups scheduled for the coming weeks, and hope to gather more data to better understand the process of treatment-seeking in these communities. In the meantime, my research assistant and I are working on making transcripts and staying dry in the midst of heavy monsoons.

Sunday, June 24, 2012

Trauma and Critical Care at Charlotte Maxeke Johannesburg Academic Hospital in Johannesburg, South Africa, Jayamaran

Sudha Jayaraman MD MSc
Fellow, Trauma Burns and Surgical Critical Care
Brigham and Women's Hospital

Pictures worth a 1000 words....

This is a CT scan of the chest of a young man with stab wound to the chest - he was hemodynamically stable on presentation but the location of the wound was concerning for cardiac injury and risk of tamponade. Because echocardiography is not readily available, a CT was performed and shows substernal air pockets just anterior the heart and aorta. While he may have been observed in the ICU and followed with serial echo exams in the American setting, lack of close monitoring capacity in the ICU, difficulties in mobilizing an operating room in case of sudden tamponade and lack of echo facilities meant that this patient needed an immediate pericardial window and if positive, a sternotomy to assess and possibly repair the likely injury to the heart.

Below- Intraoperative photograph showing open pericardium with a small (2mm) injury to the right heart. The injury had stopped bleeding and did not require further repair. This was a non-therapeutic sternotomy.

Trauma Resuscitation Bay in the Emergency ward at Baragwanath Hospital. Up to 16 patients can be managed and ventilated at one time. Considered the largest trauma center in the world.

Milpark Hospital, a private facility for insured patients, has a beautiful 30 bed Trauma ICU and a 10 bed Burn ICU, pictured below, with state of the art equipment and staff. The helipad is right in front of the entrance.