Saturday, February 22, 2014

Thankfully we were also able to experience a little Vietnamese culture throughout the two weeks. I have posted several pics, including our visit to the Chu Chi Tunnels ( a major communist community that was a major battle ground during the Vietnam War). As you can see, we were able to explore the tunnels. It was a little claustrophic for sure!

Below are pics from our trip to the Mekong Delta, a small region south of Ho Chi Minh City, which is home to approximately 30 million people.

Vietnam is famous for it's vast selection of tropical, delicious, fruits. Truly the best fruit I have ever had.

Sadly, here is a pic of one of my final clinic days with Dr. Minh and Dr. Famy. This morning we saw 96 patients in a half day! Such a need for dermatology here. The work ethic of these physicians is just phenomenal.


Greetings from Vietnam!

I have now been working with the brilliant dermatology faculty and residents of Ho Chi Minh City College of Pharmacy and Medicine for one week and I must say this has been one of the most memorable and impressionable learning experiences I have encountered throughout residency. 

A little background for you….. For years, the country of Vietnam has lacked the appropriate means for effective, early intervention of disfiguring vascular anomalies.  The standard of care has historically included the use of radioactive phosphorus for infantile hemangiomas and even in some cases vascular malformations. This treatment is not only painful for the children but leaves behind disfiguring, stigmatizing, and painful scars, many of which are located in the facial region. Five years ago, Dr. Thanh Nga Tran and Thuy Phoung (both natives of Vietnman) decided they would put a stop to this treatment once and for all. Both having trained in the Harvard Dermatology and Dermatolopathology programs respectively, they determined to join forces with Dr. Rox Anderson (expert in the laser and medical treatment of vascular anomalies) and Dr. Martin Mihm (expert in vascular anomalies and dermatopathology).

Dr. Tran spent one month at the Ho Chi Minh College of Pharmacy and Medicine as a senior dermatology resident and during this time made contact with two of the most honest, hard-working, and caring dermatologists any of us has met, Drs. Hoang Minh and Bo Famy. Together, this remarkable team of physicians established the first vascular anomalies clinic of Vietnam five years ago this month.

The clinic began with 1 laser, the pulsed dye laser, an operating room with anesthesiologist, a team of eager residents, and of course a line of patients. Through much fund-raising and generous donations from various laser companies, the OR is now replete with the top four lasers needed for the treatment of various vascular anomalies. This accomplishment in only five years time is truly remarkable.

Now for the present…..Upon arriving in Vietnam at 1:30 AM, the hospitality of this program was evident immediately. Second year resident- Anh Dao was there with her little brother holding a sign with my name as soon as I exited the airport in Ho Chi Minh City. I must say this was so comforting having never been to this country and not speaking the language.

Our first day in clinic was truly an eye-opening experience. It began with the evaluation of several children with disfiguring scars from the treatment with radioactive phosphorus. In the year previously, Dr. Anderson was able to bring a new device that he invented which harvests a “blister graft” from the thigh, which can then be grafted to the site of a scar (after superficial epidermal ablation).  He trained Drs. Famy and Minh on the utility of this device and they were able to treat several of the children in the last year. The results are truly remarkable!  Nearly normal pigmentation and texture resulted. This is life changing for these children whose scars are located in the facial region. Additionally, this is ground breaking in the treatment of radiation injury. Thankfully, we were able to treat several additional children during our time this year.

Additionally, we evaluated and treated numerous children with hemangiomas, capillary malformations, lymphatic malformations, and venous malformations.
It was amazing to observe how brave these children are here. They literally walk into a room of 15-20 physicians and sit in the middle quietly while we discuss the treatment plan. 

A great deal of our time was also spent teaching the residents and attendings how to develop treatment plans, including the use of medical management, such as topical timolol and oral propranolol, in combination with laser treatment.  At the end of the week several members of our group spoke at the annual CME conference held at the University. Much to our surprise, this year’s attendance hit a record high of over 500 doctors from across Vietnam!

Monday, February 17, 2014

Collaboration in Pediatric Medical Education and Clinical Care in Mbarara, Uganda

I walk into the admissions room for the “Toto” Pediatric Ward at Mbarara Regional Referral Hospital in Uganda and the intern on-call looks up at me with an anxious smile.  In this room there is a small bench, where two mothers sit with their toddlers, prostrate on their laps, one tachypneic, the other pale with visible scleral icterus.  The intern is admitting both children - checking vitals, writing admission notes, placing orders, inserting IV catheters, and ensuring these two patients receive their medications promptly.  I glance over at the single exam table where there is a small bundle – I lift the blanket and find two premature twins, each less than 1kg, swaddled together under a bare bulb for warmth.

Thursday, February 13, 2014

Thoughts from Bangalore, India: The East Teaching the West in Mental Health

When discussing global mental health, the conversation often focuses on whether psychiatrists can practice outside of their cultural context. What we sometimes forget is that psychiatric illness is organic illness of the brain, affecting equally large percentages of the world population from nation to nation. Illnesses such as bipolar disorder, autism, depression, OCD, schizophrenia and other mental diseases occur beyond cultural boundaries and they deserve a global conversation.  We know that Western thought and philosophy in this area is only about 150 years old; this begs the question of how ancient civilizations effectively treated mental illness.

Through my Partners Center of Expertise grant, I’ve been involved in some psychiatric cultural studies at the National Institute of Mental Health and Neuroscience (NIMHANS), a central government research institute pushing forward the fields of psychiatry, psychology and neuroscience in India. Here, they have an Advanced Center of Yoga where they are building modules of yoga postures to treat various mental illnesses. In modern society, yoga has been considered a type of exercise, but traditional yoga born and propagated throughout India, is a multifaceted way of life used to help practitioners increase their self awareness, flexibility in thought, and feelings of security. It focuses on a holistic sense of health, a beneficial perspective in mental illness. The Advanced Center for Yoga at NIMHANS is running multiple studies in yoga and has recently published a supplement in the Indian Journal of Psychiatry. This describes multiple controlled studies that show yoga improves quality of life and sleep in elderly, has antidepressant affects on the general public, and improves symptoms of ADHC, psychosis, dementia, and memory. The center has made yoga a standard therapeutic intervention and I have been lucky to be invited to experience the clinical treatment of patients here.

While the focus for my global health project is on cultural contexts in diagnostic practices of academic psychiatrists, I wanted to highlight the yoga center in the blog. It is a perfect example of why the study of psychiatric disorders should be global and why communication and teaching in global health should be a two-way street. It also highlights the need to put some thought into broadening our scope in psychiatry rather than limiting it due to cultural differences. See pictures of the Yoga Center below:
 Here is the entrance area to the Yoga Center at the National Institute of Mental Health and Neuroscience

This is a class that uses the yoga model for anxiety related illness.

Jhilam Biswas, MD

Forgot to ask you...

My plan in Guwahati was to start launching our research project on quality of life of people suffering from cleft disease.  Even though the estimate is that 1:500-1000 children are born with cleft disease, it remains to be defined what the burden of this disease is, as in United States and other high-income nations, all these cases receive surgical repair, along with dental, speech, and psychological support right at the beginning of life.  But Guwahati, is a different place.  Here resources have been scarce and the majority of the population lives on what they make as farmers for big plantations of the world-famous Assam or Darjeling teas.  There is an estimated backlog of 30,000 cases of cleft disease and that also means, unfortunately, a lot of people with cleft that are reaching adulthood without having received any care.  I knew this, and this was precisely what attracted me to Guwahati.  In preparation for this trip, I tried to educate myself on how is cleft disease seen in the global health arena.  What I found was that cleft was lumped in a category known as “congenital deformities”, where club foot, polydactily, etc. were also a part of.  And it was thought of as a condition that had very low mortality and low morbidity, so therefore, it ranked low for disability-adjusted life years (DALY’s), a common currency metric developed to compare conditions against in each other and ultimately, have a priority setting that the United Nations, World Bank, World Health Organization, countries’ ministries of health and funders all refer to when making their own agendas and resource allocations.  Surprisingly, cleft patients were not part of the process of obtaining an idea of what disability cleft disease carried, especially if it remained untreated.  That is exactly what I set myself to do and Guwahati seemed like the right place to do it. 

As I trained the research assistants, who were 3 pleasant Assamese women, all in their early twenties, all with masters in social work or child development, I started to wonder, how much of these questions on quality of life, written and validated in developed nations with likely way more education than the patients coming into the center had ever had, were really going to get through to them and the patients we were about to interview.  But, I kept on and asked the questions.  I would simplify the phrases when necessary and assess their body language to see if they understood me.  But still I wondered. That is when I interviewed Kiran (named has been changed), father of 7 year-old, Meena (name has been changed).  His girl was about to have surgery that day, and they had come 8 hours away by bus.  I asked her about his Meena and how she was feeling about getting surgery.  As the translator explained to me, his girl had been suffering in school as she was teased for her cleft lip and palate, because her mouth looked funny and kids could not understand what she said.  She wanted to play with the rest of the kids, she wanted to be liked by her peers.  He shared that as soon as she found out that there was surgery that could fix her cleft lip and palate, she asked her father daily, “when will you take me to get the surgery?”  I tried to hold my own sadness, thinking how her father must have looked into her child ‘s pleading eyes, and wonder how he could help her.  But now she was here and his father’s broad smile, revealed to me, this was not a moment to dread or to be nervous about, this was a moment of joy.  He said that his daughter will go back and go show everyone her new lip, that she is already talking about that moment.  And as I listened to him, despite the world of experiences that set our lifes in different directions, I understood and I could hear Meena through her father's story, loud and clear.

Just in!

After 27 hours of travel, Dr. EJ Caterson and I landed in Guwahati, India.  Even though neither of us had ever been here, the place has the familiarity of any town in the so-called “developing” nations.  It reminded me of the border towns in Lima, Peru, of the South countryside of Dominican Republic, of the Mayan towns away from touristy Yucatán, of some of the forgotten towns around my own hometown in Puerto Rico.  The half-painted, half-roofed and half-built buildings, the dust that deposits in everything living or nonliving, the entropic flow in the narrow streets full of motorcycles, cars, cows and many street dogs, all avoiding collision and the road holes with miraculous success. 

But we were decidedly in India, with the women in saris coloring the streets, the incense in the air, the glimpses of gold against the beautiful dark skin, the cricket fields and the ever-present crowds.  We had gotten the first welcome to the Monsoon when we landed in Mumbay with a loud rain at 2 am.  Now the rain had passed and the tropical humid air damped our foreheads as we went from the airport with a quick stop to drop our luggage and into the hospital to start the real adventure. 

What had started as a dreamlike conversation on evaluating delivery of surgical care in low-resource settings one afternoon a year ago in the HMS green lawn with my mentor, Dr. EJ Caterson, was finally having a home with discrete GPS coordinates in the real world.  The home for this project was located in the public hospital of Guwahati, in a ward donated by the Assam government to Operation Smile India, as part of a public-private collaboration between the two.  This collaboration expanded beyond the hospital, as the community health care workers, known as ASHAS, were trained by the personnel of the center on how to recognize the condition and refer it to Operation Smile, reaching statewide coverage and even neighboring states.

As you walked through the hospital, bare-bone conditions with windows overlooking trashed green areas transitioned to the newly painted murals and order of the Operation Smile Center.  Inside the glass doors that led to the center, blue painted walls sheltered a waiting room, the administrative offices, dental, speech pathology and nutrition offices and even a play area with toys and facemasks for the children to familiarize themselves with the strange objects they will be in contact with in the operating room. 

All shoes off and scrub shoes on, we get into the perioperative area.  The operating room consists of a large room with 5 operating tables with their ventilator machines, like Siamese twins, all lined-up, with that aseptic smell and look, universal to operating rooms.  In the operating rooms, I relax, as I watch or assist the attending surgeons, as this room is familiar and a respite from the over stimulating of colors, odors, and movement in the busy streets of Guwahati.  I secretly preferred being in here, where I felt useful versus the streets of Guwahati, where in Yesterday’s walk to the hospital I had encountered a 3 year-old child with sunken black marbles for eyes laying on a dirty blanket with a tin bowl by her side and a head bubbled by untreated hydrocephalus, among piles of tropical mangoes, guavas, bananas, and street trinkets for sale.

Inside the operating room, I marveled.  I marveled at this well-oiled machine of cleft surgeries biting away at the more than 30,000 untreated cleft cases in the state of Assam.  Biting 1/3 of the burden of the disease in only 2 years!  Firm and steady bites of well thought, protocoled, state of the art, high-standard surgery.  This is what I wanted to see, this is what resonated right in my heart, the idea of the best we have to offer for all, the truism of the universal declaration of human rights soft murmur, now in the loudest decibels screaming “it can be done” in the off-the-map and off-the-beaten-path and off-the-charts Guwahati.