Monday, October 28, 2013

Alaska, USA - Isaac Benowitz, Resident in Pediatrics, Massachusetts General Hospital - Health Disparities of Alaska Natives

September 12, 2013

Access to water has been described as a basic human right. I'd heard plenty from my medical school classmates about the challenges of bringing water to poor villages scattered across Africa but I didn't realize there were places in the US with similar challenges, places where water isn't taken for granted.

I'm out in rural Alaska, "the bush," far away from the "big city" of Anchorage (which at 350,000 has half the state population). I'm in Bethel, Alaska, population 6,000 people and probably as many dogs, all-terrain vehicles, and snowmobiles (or "snowmachines" as they're called here). I've spent the past few days here working with the environmental health team of the regional native health corporation that provides for the health needs of 25,000 people, mostly Alaska Native, spread out across 50+ villages and communities in an area the size of Oregon. This is a tough place to live for the mostly poor native populations in the rural villages. They lack the oil that brings wealth to villages much farther north, and the fishing and tourism that are prevalent in many other parts of the state. Access to clean water for sanitation and cooking is one of the basic challenges out here.

Most of the villages out here historically had third-world rates of invasive bacterial diseases: pneumococcal pneumonia, haemophilus influenzae meningitis, and soft tissue infections, until not long ago. Vaccines made some headway but that's an incomplete solution. In areas where piped water has been brought in, disease rates dropped much farther. There has been a push to improve the access to basic sanitation, to provide better access to plentiful clean water and disposal of sewage, but the implementation is a persistent challenge. There's plenty of water out here at least in some places, in the rivers and lakes and the ocean, but it's expensive to treat and difficult to transport to houses. The Arctic provide some tough obstacles: the ground in this whole region is soggy and unstable and so it can't maintain water pipes, and anything above ground is incredibly expensive to keep warm when the nighttime temperature hovers in the single digits (Farenheit) for 3-4 months of the year and record cold weather dips to -45 F. Sewage disposal faces similar challenges (and freezes a lot harder than water). Supplies to the region come by cargo barge up the river, or by cargo plane, during the short summer here; in the winter, the rivers freeze solid enough that people can drive on them with snowmachines and light trucks but cargo can only come by plane. The area is rich in fish and berries but poor by most other measures. The regional health corporation is quite proactive, though, and has worked with the state and the individual cities and villages to get better sanitation to the people here. In the past, a village would have a central water distribution plant where people filled small jugs and transported them home by foot, all-terrain vehicle, or snowmachine; human waste was collected in a "honeybucket" and then dumped in each neighborhood and then towed to the village sewage lagoon.

There is an on-going initiative to bring piped water to every home in Alaska, and it faces an array of uphill battles in places like the YK Delta where many people live in villages with only a few dozen people, and the nearest real infrastructure is 20 or 50 miles away with no roads in between. Several years ago an ambitious project installed water tanks, low-flow toilets, and sinks in most of the houses in a handful of villages, using all-terrain vehicles in the summer and snowmachines in the winter to haul water to homes and haul sewage away to nearby lagoons. And they disassembled any remaining infrastructure supporting the older systems that were phased out. The system was great in principle but it has problems. The first is that over the years we've learned more about the amount of water the people use on a daily basis for what we'd consider a modern lifestyle, and we've also learned a lot out here about the economics of water utilization. And it turns out that at the price point that this water is available, and the quantities in which it's delivered, there isn't nearly enough water coming into these homes to really use water the way we all do in our homes. There's enough water to cook food. There's running water in a bathroom and a sink and a toilet, but people ration water by putting a bowl under the sink and reusing the water several times. People have simple agitation clotheswashers and it's quite common to run 5-6 loads of clothes in the same water until it turns grey or black.

I spent the last two days on a house-to-house survey of these failing water systems in a small village in the YK Delta. More recently, some of the villages with this "flush tank and haul" system have run into some serious maintenance problems that are, at some level, representative of everything wrong with these novel solutions to the water challenges out here in bush Alaska. The toilets in these homes, low-flow toilets purchased at great cost from Japan to reduce water use, are failing in simple ways, and there are no repair parts here. (Apparently the toilet flush handles were made in a factory in Japan that fell in an earthquake, and it's not clear that anyone is making more replacement parts now.) There are some repair parts floating around but people are unwilling to pay steep prices to make repairs to a system they never totally bought into in the first place. The toilets flush sewage to tanks outside the homes and workers pump out the sewage to transport to a lagoon, but the pipes that connect the homes to the tanks are falling apart. In many instances they've frozen in the winters leading to more severe damage. When people stop using this tank system, they start dumping sewage anywhere (next to their homes) which is pretty unsightly and it also means that there aren't as many fees pouring in to support the system that remains. We found all the problems that I've described above, and a village with limited means to repair a failing system. After I leave, the rest of the team will work with the village and the community to find ways to repair the system, but it's not clear where that funding will come from (this system probably cost $5 million for a village of a few hundred people, but there's no repair fund leftover) and it's not clear whether this system is viable long-term.

On a small scale, the fixes are easy in villages like the one I visited: find a repair person, find funds to pay them to get the system running again. There are other villages nearby where there's more funding, and maybe two or three people that know how to do the maintenance work, and things work better. But on a larger scale, though, the water and sewer system in that village is probably destined to fail because what made sense a decade ago no longer seems sustainable and maintainable. The state is sponsoring the "Alaska Water-Sewer Challenge," inviting bids from around Alaska, and around the world, for the next greatest system, or set of systems, to tackle the complexities of bringing adequate supplies of water, and adequate sewage removal services, to all these small remote communities. It's frustrating and disturbing to find entire communities in the US that we haven't managed to bring up to modern sanitary standards. As I head back to Anchorage and then back to Boston in a few more days, I leave with a sense of hope. There are big challenges here in Alaska, with providing basic services to these remote villages, are big challenges. But I also met a lot of highly-motivated, dedicated people, young and old, Alaskan and from elsewhere, here working to address these health disparities, and I'm hopeful that they'll persevere, with more initiatives and iterations, and see progress in our lifetime.

And as I head home, I'm incredibly grateful to all the people and organizations that made it possible for me to come out here, learn about all these challenges, and help think about how to address them. Thank you to Tom, Ros, Mike, Prabhu, and others in CDC's Arctic Investigations Program for letting me join them for the month. Thank you to Jenni at the Yukon-Kuskokwim Health Corporation for the opportunity to head into the field and learn about environmental injustices on the American frontier. Thank you to MGH Pediatrics for letting me slip away for a month. And thank you to the Partners Center of Expertise in Global and Humanitarian Health program for financial support of my travels!

With limited water coming into each home, people ration water by putting a bowl under the sink and reuse the water.
The village spigot. This village is large enough to have centralized water treatment, but with soggy ground that can't support pipes, and freezing temperatures that make above-ground pipes a recipe for freezing, they rely on ATVs and snowmobiles to carry water to each home and haul sewage away.

Going house to house to survey the state of the "flush tank and haul" systems in a small village in rural Alaska.
Heading back from a village visit, by small motorboat on one of the winding rivers in Alaska's YK Delta.

Alaska, USA - Isaac Benowitz, Resident in Pediatrics, Massachusetts General Hospital - Health Disparities of Alaska Natives

August 26, 2013
Greetings from America's frontier! I’m spending a month in Anchorage, Alaska, working with the CDC’s Arctic Investigations Program. I came to pursue some interests in the social determinants of health and environmental health, chasing an opportunity to work alongside CDC researchers who study health issues in Alaska Natives and other Arctic populations and to dabble in some of the diverse applied public health and epidemiology projects going on here. Alaska has a population of 700,000 people, including about 150,000 Alaska Natives, a term that describes people from several different tribes. Some people of native heritage live in urban settings and have a health status similar to others in modern cities, with relatively good access to clean water, clean air, access to healthcare. But there’s also a huge native population living in small remote rural villages where they rely on subsistence fishing and hunting and gathering, live in simple homes that often lack adequate ventilation of wood stove fumes or running water and sewage services, and have fairly poor health status. A small, cramped home makes sense way out there, despite all of the available land, when you're thinking about the heating bill for the long and harsh winters up here with prolonged stretches of sub-freezing temperatures. It’s disturbing, and amazing, to find places in the United States without abundant clean running water in homes, but there are several villages where there is no public water supply, or that supply is a pump across town, or there is an infrastructure to distribute clean water to homes but people can’t afford the bills. These villages have experienced very high rates of invasive bacterial diseases: Haemophilus influenza, meningococcus, strep pneumoniae, and skin and respiratory infections from staph aureus, as well as tuberculosis in some places, but gains in vaccination rates have turned the tide on much of this. Diets are a mix of traditional foods (think about lots of heavily-preserved fish and game meat... and the occasional whale feast!) and more modern foods brought in from outside. Transportation is a mix of boats on rivers in the warmer months and snow machines (snowmobiles) in the long winters.

I have a few projects to jump into for my time here, in addition to getting a flavor for other work in progress here. This research group at CDC works closely with the Indian Health Service, a federal agency that provides healthcare to native populations across the US, including Alaska Natives here in Alaska and American Indians elsewhere, in their own clinics and hospitals and as an insurance provider. There has been an observed rise in rates of hospitalizations in Alaska but nobody has taken a big-picture look at the IHS hospitalization data to examine trends by year and by diagnostic category, so I'll be pursuing some health services research analyzing hospital admission data. Next, there is a long-observed increased burden of skin and soft tissue infections in the Yukon-Kuskokwim Delta, a region of Southwest Alaska the size of Oregon, with 25,000 people scattered across 50 rural villages with most populations under 1,000. We know that much of this is related to poor overall health status (similar scenarios have been studied in indigenous groups in Canada, Australia, and New Zealand) but the challenge is finding workable ways to reduce the significant health burden of these skin infections. Prior field investigations and studies identified several factors that contribute to boil development, including overuse of antibiotics for respiratory conditions (leading to the development of resistant strains), poor general hygiene (many people shower once a week, with no soap) and communal steamhouses (tiny sweat lodges, build from plywood, where as many as eight people may cram into one sauna session) that allow for skin-skin contact and biofilm formation which both predispose to MRSA transmission. The regional health corporation (like the county health department for the tribal population) asked CDC to recommend ways to reduce the burden of MRSA carriage and boil development; I’ll be helping to select intervention strategies and conduct environmental testing to let us better define MRSA transmission dynamics. CDC is also pursuing several projects related to the burden of human papillomavirus (HPV) ranging from studying virus stereotypes in tissue samples to starting a vaccine effectiveness trial for HPV in native teens (the effectiveness will depend on whether the same strains are prevalent up here as in the rest of the US), looking at titer levels in teenagers over several years, and if I have time I’ll help recruit teenagers into this study designed to determine whether the three-dose vaccine series works as well in the Alaska Native ethnic group as it does in other populations where it’s been studied.

And in the time that remains, I hope to explore a few parts of Alaska. It’s gorgeous in Anchorage this time of year (August-September), a little rainy mixed with some sun, but with temperatures in the low 60s and long days with an evening glow that lingers for hours before the sun dips over the mountains around 9pm. Many people who live here love fishing in the rivers and in the ocean, hunting, boating, cross-country skiing, hiking, and running. It’s not just people in rural villages who value subsistence: one researcher here explained that it’s so easy to live off the land, so easy to fish, hunt, collect berries, and grow vegetables in a garden in the short growing season, that Alaskans consider it an indignity to go to a market for any of those foods instead of diving into their deep freezers.

 Arctic Investigations Program is CDC's outpost on the American frontier.

Every presentation from the CDC Alaska group had a picture of a moose, so here's mine.

It's gorgeous in Alaska in late August. Here's a wildflower on a hike a few hours outside Anchorage, with a high mountain stream in the background.

Sunday, October 27, 2013

Harare, Zimbabwe - Jessica Magidson, Postdoctoral Fellow, Chester M. Pierce, MD Division of Global Psychiatry, MGH - Improving depression and HIV medication adherence for health care workers

Greetings from Harare, Zimbabwe (or “Mhoro” in Shona… I’ve been slowly trying to learn Shona, the most commonly spoken language in Harare). I am here with Dr. Conall O’Cleirigh, a mentor of mine in the Psychiatry Department and Behavioral Medicine Service at MGH, and our gracious hosts, Dr. Melanie Abas, Dr. Frances Cowan, and Dr. Dixon Chibanda from King’s College London and University of Zimbabwe College of Health Sciences (UZ-CHS).

We are here leading a three-day training at UZ-CHS to train health care workers on brief, empirically-supported behavioral interventions for improving HIV medication adherence. Adherence in this setting is crucial, as in addition to consequences of HIV medication nonadherence that we see in the U.S. (lower levels of viral suppression, accelerated disease progression and mortality, production of medication-resistant HIV strains, and potentially greater likelihood of HIV transmission to others to name a few), there is also a reality here that when individuals fail first-line antiretroviral therapy (ART), there may be limited ART treatment options. As a behavioral intervention to improve ART adherence in this setting, we are focusing on Life-Steps, a single-session cognitive behavioral and problem-solving-based intervention for improving medication adherence. Life-Steps has been developed and tested by MGH faculty (Safren et al., 1999) and implemented in international contexts, including South Africa, although this is the first formal training and implementation in Zimbabwe, and modifications have been made for this setting.   

Day 1 of the training was a larger training – ‘master class’ – open to a wider group of students, health care workers, and faculty as part of a capacity building initiative “Improving Mental Health Education and Research Capacity in Zimbabwe” (IMHERZ). This initiative focuses on bringing together leaders in global mental health and capacity building expertise from partnering institutions primarily in South Africa (University of Cape Town) and London (King’s College London) to increase availability of academic training in Zimbabwe as well as to offer exchange opportunities with partnering institutions. We were invited to teach a 3-hour ‘master class’ to present the current state of the science on behavioral interventions for improving ART adherence and train the group in Life-Steps specifically. Prior to the training, we received input and feedback from local providers and faculty regarding how to culturally tailor the material to make the training as relevant as possible for the Harare context. There were over 60 people in attendance across numerous disciplines, and a few clinical psychologists in particular emerged as leaders within the group to aid in the tailoring and teaching of the material. That evening, the IMHERZ team held a dinner for us at a private home – we had a feast of Ethiopian food and the discussions continued. 

Dr. O'Cleirigh leading a role play during the IMHERZ master class

The second two full days of clinical trainings were conducted with a smaller group of health care workers (ART adherence counselors and in-training psychologists) and psychiatry department faculty. This part of the training was to provide more hands-on instruction and supervision for local providers who will be beginning to implement these interventions in local ART prescribing clinics, as well as guidance for the psychologists who will be supervising the providers. In addition to continuing a more in-depth and hands on training of Life-Steps, we discussed specifically the way in which symptoms of depression interfered with medication adherence, and how brief, empirically supported treatments for depression could be delivered alongside ART medication adherence interventions. Specifically, we trained the counselors briefly on behavioral activation (BA) for depression and problem solving therapy (PST) – although this proved to be, in my perspective, the most challenging part of the training.

Discussion of local barriers to ART adherence (listed on the board) with local students in attendance and our host Dr. Melanie Abas
One of the key challenges that emerged was that there did not seem to be a consensus for a term for ‘depression’ in Shona. There is a well-documented clinical phenomenon in Zimbabwe called “kufungisisa,” which translates as “thinking too much” -- this was actually just included as a ‘cultural concept of distress’ in DSM-5, the version of the Diagnostic and Statistical Manual of Mental Disorders released in 2013. In some cases kufungisisa has been seen as synonymous with the manifestation of depression in this culture, yet upon further discussion within our group of psychiatrists, psychologists, and health care workers during this training, it became unclear if kufungisisa always reflects a true clinical depression. We had fascinating discussions as a group as how to distinguish when kufungisisa reflects depression, or when it’s a normal human experience given the context of immense psychosocial stress, poverty, and violence. It also emerged that the ART adherence counselors who we were training (with no previous mental health experience or training) identified “stress” and their notion of “depression” as being synonymous. Although the DSM and our training in psychiatry and clinical psychology routinely and importantly make this distinction, I began to wonder how important these distinctions were in this context for our training and for the delivery of empirically supported interventions in this setting, when in fact many of the intervention techniques are effective across stress and depression, and both of which can interfere with adherence. We had to strategize at this point what would be the most efficient and effective focus for our remaining training sessions. 
With our host and the team of adherence counselors and supervisors who were trained in Life-Steps and will be implementing Life-Steps in local ART prescribing clinics