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

Disparities, conundrums and contradictions

The most striking aspect of my visit to Joberg was the recognition of disparities on many different levels. I didn’t realize that South Africa has among the highest Gini coefficients of all the countries around the world per the World Bank but I certainly noticed it very quickly during my trip. (The Gini coefficient is a measure of income inequality with high values indicating greater disparities in income distribution.)
Obviously there are disparities between the US and SA in the quality of healthcare which is largely related to disparities in health care funding between the two countries -18% of GDP in the US is spent on health care versus 9% is SA per the World Bank.

However, disparities in income and class were quite stark. There is a clear predominance of black South Africans in the public hospitals, for example, compared to the wealthier white and Indian population in the private facilities. This difference was noticeable in general society as well. Joberg is known for its fancy malls with all the most famous high-end European and American clothing and accessory shops. Visit one of them and disproportional distribution of black waitstaff and a largely white clientele is quite obvious. Capetown, which I visited for 2 days, had the same skew in the staff and clientele in the posh restaurants lining the coast.

There were also striking disparities in care between hospitals in Joberg. I was struck by the differences between the public and private hospitals in the city. While the same surgical faculty worked at both the public hospitals (Joberg Gen and Baragwanath Hospital) and the private hospitals (Milpark and Donald Gordon), I could not help but notice the differences in resources between these facilities. The 30 ICU beds at Milpark that are solely allocated to trauma patients compared to the 4 ICU beds at Bara which meant that a ventilated patient at Bara might end up on the general surgical ward along with 60+ other patients.

The disparate burden of trauma, especially on black versus white and Indian children, was painful for me to see, especially as a mother of an active three-year old. Every day I passed kids of all ages as I walked through two of the most elite private prep schools in the country on my way in to the hospital – St. John’s (boys) and Rodean (girls). The schools were largely filled with white and Indian children with a significant but small minority of black children. The casualty ward at Joberg Gen told the opposite story every night.

The first Friday and Saturday nights I spent on call I saw five young black South Africans die. They were between the ages of 15 and 30.

At Bara, on one of the few nights I visited, I saw four black children, from different families, present with large burns. They were all under the age of three.

It is winter in Joberg and the evenings/nights can get quite cold (30s Fahrenheit). Poorer families often use open air fires for warmth or for cooking and children can easily become casualties.

Ninety percent of deaths from injury happen in low and middle income countries while the majority of research and funding for trauma are focused in high income countries. My visit to Joberg Gen only made me more acutely aware of that disparity and made me more convinced that I should be part of efforts to change that inequality.

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

Community Health Workers and expanding primary care in rural Uganda, Paul J. Krezanoski, MD

Another discovery on my recent trip to Uganda is the growing use of technology to augment the ability of lower skilled health workers to improve care delivery. The Healthy Child Uganda cell phone project, funded by an aid organization from Canada, is a perfect example.

They have piggy-backed a cell-phone based technology project onto a Uganda national government initiative to utilize communty based health workers. These health workers are designated by their communities as respected leaders at the village level. Depending on the size of the village, there is usually 1-3 CHWs identified. Their typical job is to help with training and mobilization for vaccine campaigns and other national priorities.

Healthy Child Uganda has rolled out a full scale point-of-care treatment program using cell phone technologies. They have programmed phones with interactive algorithms that CHWs use to treat the patients they see in the villages. Using the age of the child, the symptoms and a checklist of red flag symptoms, teh algorithm designates intital treatment options (amoxicillin for fast breathing (?pneumonia) or artersunate for fever (?malaria)). Then, based on the symptoms, the phone will recommend referral to a local clinic and automatically update that clinic of what to expect via a web application.

They are using this platform for stock delivery of medications at the CHW and clinic level and have a sophisticated web application which provides real-time data about what cases the CHWs are seeing in the field categorized by age, symptom and geographic location.

The hope is that these sorts of low-end technological solutions are gonig to allow the health systems in poor countries to overcome logistical challenges to provide higher quality primary care in remote locations. I thought this was a great example of that concept.

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

I joined the Trauma Unit at the University of Witwatersrand Medical School, Charlotte Maxeke Johannesberg Academic Hospital at a volunteer faculty surgeon for a few weeks last month.  It was my first time in South Africa although I had worked and travelled in Uganda and Mozambique before. 

I chose to spend some time at this particular hospital for several reasons.  This hospital and it's sister facility (Baragwanath Hospital) are world renown as high volume trauma centers and have produced many international leaders in trauma care such as Dr. Demetriades (Chief of Trauma at LA County/USC Hospitals) and Dr. Velmahos (Chief of Trauma at MGH), among others.  As such, these two facilities draw visiting faculty, trainees and medical students from around the world.  As a Trauma and Acute Care Surgery Fellow at the Brigham, I was drawn to visit, observe and participate in these settings which trained some of the most remarkable surgeons in my field.

Furthermore, I am particularly interested in how systems of trauma and emergency services are developed, both locally in the United States and globally.  Through a collaboration between UCSF and Mulago Hospital in Kampala, Uganda, I was able to work on injury-related research during my residency and plan to continue work along those lines in Rwanda in the upcoming years through BWH/PIH.  Thus I have wanted to learn about how the South African health system is set up to address trauma and emergency services and determine what lessons I can gather for my upcoming work in Rwanda.

Here are a few photos from my first day at Joberg General.  It was a fantastic institution to visit and a great group of faculty and residents to work with during my three weeks there. 

More postings to come about the details of my time there....

Sudha Jayaraman MD MSc

Fellow, Trauma Burns and Surgical Critical Care

Brigham and Women's Hospital

Univ of Witwatersrand Medical School

Charlotte Maxeke Johannesberg Academic Hospital (Joberg General)

Trauma Resuscitation Bay




Bedside in the Trauma ICU

Use of bednets in rural Ugandan households, Paul J. Krezanoski, MD

My work in Uganda is related to understanding the determinants of the use of bednets. These insecticide-treated nets have the potential to dramatically improve the lives of pregnant women and their children. Mere ownership in a household has been correlated with a 20% decrease in mortality among children under 5 years of age.

Uganda and especially western Uganda, has a very high level of malaria. It is a significant burden on the health system and leads to lives lost and time away from work. Bednets are often too expensive for households and even when they own them, they don't always use them as they are meant to be used.

I spent multiple afternoons visiting households in rural villages trying to understand the barriers to bednet use. This usually involved trekking into the banana trees with a local health worker and showing up at households. The first thing they would always do is invite us in to their homes. No matter how poor, they always invited us in, asked us to sit and thanked us for coming.
In many of the households, the walls were made of crumbling mud caked onto wooden frames. The ground was packed dirt and there were only a few small (small) rooms. The bednets I saw typically took up the whole space of the bedroom. Challenges included keeping them clean, finding creative ways to mount them in such small spaces, and finding ways to put them up adequately over sleeping areas.

I spent a lot of time asking people about their perceptions of bednets and their understanding of why they are used. We also discussed local programs for bednet distribution and ways that the people thought these programs could be improved. Often I would talk with the village health worker after I'd left the houeshold to get the "real scoop" about that household's malaria behaviors. I heard about husbands who refuse to sleep under the nets for fear of reducing their sperm count. I heard about how nets make people too hot so they aren't used in the humid rainy season (the time they are most needed). I heard about bednets made into wedding veils for local celebrations.

There is much to learn about how this technology makes it way into the real lives of local people. And that is where I am focusing my work.

Paul J. Krezanoski, MD

Pediatric Cardiac Care in Kerala, India. Jennifer Lewey, MD

Introduction to pediatric cardiac care in India

Walking into the hospital in the morning, I immediately begin to feel calm.  The busy hustle of patients and providers rushing to their appointments; academic presentations of recent journal articles during morning conference; the complex yet highly structured ways in which medical information is communicated: these are things I know.  Having arrived in India just this week, I am grateful for these familiar rituals.  For the next 4 weeks I will be based in Kerala, the southwestern most state, at the India at the Amrita Institute of Medical Sciences.  A private hospital with over 1,000 beds, Amrita has a strong charitable program that helps to serve those who cannot afford healthcare. 

In the past week, I have had just enough time to see one cardiac surgery, five complicated procedures in the cardiac catheterization lab, and over 50 echocardiograms of children with incredibly complex congenital heart disease.  I have shadowed rounds in the pediatric cardiac intensive care unit, impressed that I understand as little here as I would have in the CICU in Boston.  I have met an incredible team of attending physicians and fellows, whose physical exam skills give me pause about what I have been learning in my medical training for the past eight years.

Yet why travel so far when I work with some of the world’s leading experts in cardiology in Boston?  The fact is that the majority of people who have heart disease do not live in Boston.  They do not live in developed countries with functioning healthcare systems that allow access to high-quality, sub-specialized care.  They live in poor countries that often lack access to even basic medical services.  I came to India to learn how pediatric cardiac care might be realistically delivered in poor countries, where access to highly trained medical staff exist- but resources are profoundly limited.

Although comforted by the daily routine of the hospital, there is nothing routine about the practice of medicine that I am witnessing here.  

Jennifer Lewey

Resident in the Brigham and Women's/ Children's Hospital Hospital Med-Peds Program

Jonathan Reisman, Pneumococcal colonization in Alaska Native people

I visited two Yup'ik eskimo villages in the Bristol Bay watershed of Alaska - Manokotak and Koliganek. While there, I participated in interviewing household members to collect data on in-home running water, household crowding, and recent infections and antibiotic use. Our team performed nasopharyngeal swabs on roughly 450 residents of the two villages. I also was able to participate in a traditional steam bath, and to try local foods such as moose meat, caribou meat, and agutak ("Eskimo ice cream") made with seal oil. I also learned about mushing and dogsleds and ice fishing, and witnessed the beginning of the massive spring migration of water birds back to the soggy tundra of Alaska. Back in Anchorage, I worked with a statistician to analyze data from similar interviews and nasopharyngeal swabs from the previous 4 years. We found that this population lives in severely crowded conditions and only 52% of all households in the eight villages of our study had running water. We found that the risk of colonization of the nasopharynx with pneumococcus was significantly increased in children living in households with no in-home running water and with household crowding. Given that Alaska Native people have some of the highest rates of invasive pneumococcal disease, getting running water to every household and encouraging birth spacing may be important interventions to reduce this health disparity.

Jonathan Reisman, Pneumococcal colonization in Alaska Native people

PGY-2 Med-peds resident at MGH

I received a Centers of Excellence travel grant to conduct a research project under the auspices of the CDC-Arctic Investigations Program (AIP) in Anchorage, AK. I studied the socioeconomic and demographic risk factors for nasopharyngeal colonization with Streptococcus pneumoniae in Alaska Native people of all ages. Historically, Alaska Native children have had some of the highest rates of several vaccine-preventable infections - including H. flu, pertussis, measles, and hepatitis B. Interestingly, in the early part of the 20th century, the Iditarod mushing race trail was used to get diphtheria anti-toxin to Nome because of an outbreak there among native children. The prevalence of many of these infections has been dramatically reduced by vaccination.

Currently, the AIP is conducting ongoing surveillance of Strep pneumoniae, as Alaska Native children have some of the highest rates in the world, and a vaccine was recently introduced. Each spring, the AIP visits eight villages in Western Alaska along the cachement basin of the Bering Sea. Interviews are conducted with families and nasopharyngeal swabs are taken. Swabs are cultured for pneumococcus, and serotypes and antibiotic sensitivities are determined. PCV-7 was introduced into this population in 2000, and surveillance studies showed that it reduced invasive disease rates. "Replacement disease" with non-vaccine serotypes was seen throughout the country, however, it was much more pronounced among Alaska Natives than in non-native populations. This suggests that colonization remains an important source of transmission of these infecting serotypes. In terms of colonization, prevalence of nasopharyngeal carriage did not change after PCV7, but rather non-vaccine serotypes simply replaced vaccine serotypes. PCV13 was introduced in 2008 and studies now are ongoing concerning infections and colonizations.

My project was to look at the last 4 years of colonization data, and to determine whether colonization is significantly impacted by risk factors such as age, gender, region of Alaska, access to in-home running water, household crowding, number of people in the house, recent antibiotic use, and recent infections. This data had not been analyzed in this way to date. I helped swab children in the Yup'ik villages of Koliganek and Manokotak.

Marjory Bravard, Mbarara, Uganda, Technology in Global Health Exploration II

Let’s talk a little bit about leapfrogging and global health technology.  The basic idea of leapfrogging is going from an underdeveloped state to a modern one without going through the historical intermediate steps.  A good discussion of leapfrogging technology can be found here.  The classic example is cellphones: countries going from few landlines to many people with cellphones, skipping over the slow creep of landline networks throughout the land.

The first great leapfrog project in global health I heard of was at Fogarty orientation a few years ago, when Krista Pfaendler spoke about her work in Zambia in cervical cancer (1 and 2).  At the time Zambia had one of the world’s highest incidence of cervical cancer, and only one pathologist who could read pap smears.  Obviously a pap-smear based screening program would not work.  This project leveraged the relative abundance of nurses and midwives relative to doctors to allow screening for cervical cancer using visual inspection with acetic acid.  A cheap digital camera is used by the nurses/midwives in the screening to ensure quality control and for assistance with clinical decision making and triage, with the assistance of an attending gynecologist.  What most impressed me about this project was the ability of a cheap digital camera to leverage the assets of a developing world health setting - nurses and midwives – to reach patients with useful interventions.  In 2.5 years the program was able to screen 20,000 women for cervical cancer in a country with a very high incidence of cervical cancer where there was previously no real screening program.  I’m incredibly impressed!  I think this is an excellent demonstration of the global health technology that works.  

While in Mbarara I checked out a few global health technology projects.  One is the UARTO study, which monitors treatment adherence in HAART treatment for HIV.  The study currently uses a device called Wisepill

to monitor treatment adherence.  Wisepill is a digital pillbox that sends a signal through the cellphone networks every time it is accessed.  If no signal is received by the study center for 48 hours, that is considered a treatment interruption and a field team goes out to see if it is a wisepill problem or if the person has stopped taking their meds, and why.  I went on an interruption visit one day (photo at left).  One of the participants we visited only needed a new battery for his wisepill, another had stopped for unclear reasons since her husband had been released from prison, and a 3^rd wasn’t home when we visited.  I think it’s an excellent approach to monitoring and helping with treatment adherence, and again one that uses technology to optimally use human resources.

In many parts of the world travelling to clinic to get results of tests costs a lot: both literally and in terms of opportunity cost with missed work. There is clearly tremendous potential to use cellphone networks to deliver test results in these settings.  Dr. Mark Siedner and I sat down to talk about a project he is developing to look at the feasibility and acceptability of delivering testing results via mobile phone.   Given issues of confidentiality and follow up treatment or testing it will be interesting to see where the project goes.  This is an under-developed area with a lot of potential.

Technology can be also used in decision aids.  Dr. Data Santorino, a Ugandan pediatrician, and I sat down to talk about a project he runs which uses smart phones to guide village health workers through algorithms for clinical decision making for treating and triaging sick children.  In this way, community volunteers with a few hours of training can used symptoms-based algorithms to treat common diseases like pneumonia and malaria, and refer to a health center when appropriate.  The data is reviewed by Dr. Santorino in the referral hospital at which time he can contact the village health worker to follow up or change triage decisions where appropriate.

Global health technology does not have to mean the fanciest new device that can detect x disease with 100% sensitivity and specificity.  To me it means the utilization of appropriate technology to leverage local assets in a way that benefits the local population in a cost-effective manner.  A development technology example I love is sanitary napkins to keep girls in school.  Educated women and their children have better health outcomes, and this is an incredibly simple way to impact school attendance.

My excitement about global health technology is its potential to help with resource allocation, clinical decision making, training, and development to be able to multiply the effect of people working hard to improve the health and lives of those in their own communities.  I leave you with a great website on global health devices to whet your appetite for the future ...

Marjory Bravard, Mbarara, Uganda, Technology in Global Health Exploration

I am a 2nd year resident in internal medicine from MGH and just spent one month in Mbarara, Uganda learning about ongoing technology research projects and working on the medical wards.  Happily, I have just received word that I was awarded a Center for Global Health Travel grant to help fund this work.  I would like to use this forum to write a bit about the setting and explore existing technology projects and some ideas for the future of global health technology.

Mbarara (at left) is a town of about 87,000 in western Uganda.  It is located only about 2 hours drive from the equator, but is at an altitude of about 1400 meters and so the climate is rather mild, although the sun is, as expected, quite hot.  Also as a result of the altitude, malaria is less of a problem here than in many lower-lying areas.  This is notable given that in Uganda, malaria is the number one cause of morbidity and mortality.  

Here are some sobering malaria statistics for Uganda (see links 1 and 2 for more):

-       cause of 25-40% of outpatient visits, 15-20% of hospital admissions, 9-14% of hospital deaths

- number of malaria deaths /100,000 population (2008): 103... Just to emphasize, that’s 1/1,000 each year

- percentage of households with greater than 1 mosquito net: 34%

- percentage of insecticide treated net coverage: 12.8%

Malaria is so ubiquitous, in fact, that in Ugandan English, the word “malaria” is used to denote fever.  With limited diagnostics, in fact, one often is equivalent to the other.  By this I mean, when in doubt, fever is treated with antimalarials (and often ceftriaxone if there is concern for bacterial sepsis) until paristemia results can be obtained.   I sat down and spoke with Margarita Riera Montes, director of the MSF Epicenter in Mbarara, to talk a little bit about their malaria work.  They are doing some studies looking at malaria heterogeneity across a small geographic area (village to village) and also looking at the use of inhaled nitric oxide as an adjunctive treatment in cerebral malaria.  Fascinating stuff – I can’t wait to see the results.

But where does technology fit in, you ask?  Well one interesting missing piece is bednet adherence.  While insecticide-treated bednets are really the core of malaria prevention (see links 1 and 2), there are no good studies that objectively look at utilization, since all studies have been done with bednet use self-reported by study participants.   So Paul Krezanoski, a co-resident of mine at MGH, is working with Data Santorino, a Ugandan pediatrician, on building a bednet monitoring device as part of a study to look at actual bednet utilization: when it is used, by which family members, and crucially, when it is not used.  This information would be critical to really gauge how best  to improve bednet utilization and also to give real data to parents on how to prevent malaria in their children.  For example, how many nights under a bednet prevent one case of malaria (number needed to treat)?  I’m very excited about this work.  It's very powerful to be able to get at the truth of utilization of bed net technology... and in the future be able to assess the impact of interventions to improve utilization.

Disability and Global Health Equity: The Call to Action (Entry 3/3)

Cheri Blauwet, MD

PGY-3, Physical Medicine and Rehabilitation

St. Marc, Haiti

Comprehensive Rehabilitation Program - Zanmi Lasante/Partners In Health

As my month in Haiti is now nearly complete, I am compelled to write about my perspective of disability as a component of global health equity. Although this concept has previously been outlined and discussed within the global discourse of health as a human right, it deserves further emphasis given that disability, unlike many aspects of chronic or infectious disease, is often overlooked within health and health care-related advocacy efforts. 

I will start with the basic facts. It is estimated via the World Health Survey of 2002-2004 that approximately 15%-20% of the global population are individuals with a disability. This figure includes those with “significant difficulty with functioning in everyday life,” and can include those with traditionally defined disability such as amputation, stroke, spinal cord injury, brain injury, etc., however also include those with disability related to chronic disease or mental illness. The prevalence of disability also increases acutely at times of natural disaster or domestic and international conflict. It is commonly accepted that individuals with disabilities remain one of our most vulnerable populations globally. As often stated in disability and
international development initiatives, “disability is both a cause and consequence of poverty.” ¹

If I hadn’t already believed this to be true, my time in Haiti certainly offered unequivocal confirmation of this theme. As initially described in Entry #2, our Rehabilitation Team continued to engage in home visits in keeping with the ZL/PIH “accompagnateur” model. With this, patients work closely with a local community health worker to create sustainable, culturally-appropriate system of medical and psychosocial support. Our Team visited patients of various backgrounds and complex needs, to include amputees (both traumatic and vascular), those who had experienced strokes, a gentleman with incomplete C2 spinal cord injury as the result of Potts, a man who had experienced tabes dorsalis as a component of tertiary syphilis, and several others. As expected, our patients had extensive rehabilitation needs such as impairments in mobility, range of motion, activities of daily living, cognition, and poorly-controlled pain. Even more striking, however, was the invariable context of extreme economic insecurity in which they all lived. Subject to difficult circumstances simply due to disability, many were also abandoned by spouses and family as the result of physical and functional limitations. Parents with disabilities were often left to raise their children alone and without a reliable source of income. Likely due to stigma, almost none were able to hold employment or vocation, leading to even greater resource insecurity and reliance on extended family members or neighbors in the community. In addition to physical or cognitive disability, many also experienced poor health due to medical conditions such as poorly-controlled hypertension and diabetes. Most were at high risk for abuse and neglect.

Given this context, it is our priority to promote psychosocial empowerment while also providing medical rehabilitative care. As a capstone of my experience and acting as an illustration of this, our team co-sponsored an event in Port au Prince focused on disability advocacy and inclusion. With this, we wished to create an environment of celebration through which people with disabilities came together to promote community. The event was titled “Respect Me,” and pocket cards as well as posters of this slogan were distributed both in English and Creole. The phrase “Respect Me” was then used as an acronym to emphasize the concepts of: respect for dignity, empowerment, support autonomy, participation, equality of opportunity, communication, tasks of daily living, mobility, and environmental accessibility. We were honored to have the presence of Gerard Oriol, the Haitian Secretary of State for the Inclusion of People with Disabilities. All in all, it was a tremendous success and a call to action for us all – physicians, advocates, leaders, followers, people with disabilities, and their colleagues/friends.

I continue to stand by the notion that an empowerment and self-respect are the cornerstone of promoting both health and health care for people with disabilities in Haiti. With this in mind, there is much more work to be done. That said, we can also enjoy and be proud of how far we have come. It is my hope that those who attended our event can carry the phrase of “Respect Me” in the front of their minds, and use it when societal barriers hold them back from achieving true health. 

¹ “Disability, Poverty and Development.” A thematic report from the UK Department for International Development (DFID). February 2000.