BWH Continues as partner in building provider capacity and health equity in Rwanda

From BWH Bulletin 8/26/16 by Jessica Zimmerman
16_08-pf_im_hrh Traumatized by years of civil war and a devastating act of genocide in the early 1990s, Rwanda used to be a place where hope was in short supply.

Over time, however, the country came back stronger than ever—investing in education, infrastructure and regional trade—and Rwanda’s economy enjoyed one of the largest growth rates in the world last year. Still, one critical resource remained scarce: health care.

In 2010, the World Health Organization reported that Rwanda had one of the lowest rates of physicians per capita in the world. A country of nearly 11 million people, Rwanda was home to about 600 physicians at that time. Most were concentrated in large cities like Kigali, leaving rural areas underserved, especially in terms of specialists.

Now that picture is changing, thanks in large part to the Human Resources for Health Program, a collaborative, seven-year project with Brigham and Women’s Hospital and Harvard Medical School (HMS), the Rwandan Ministry of Health and more than 20 other academic institutions in the United States.

Currently in its fifth year, the program sends physicians and faculty from multiple specialties to Rwanda to train the country’s next generation of clinicians, researchers and medical instructors. BWH is the lead institution for clinical faculty for all Harvard affiliates from the Boston area, and it has recruited and deployed more than 50 specialists and sub-specialists over the last four years. To date, more than 340 clinicians have participated in the program.

“This partnership was forged by something very powerful: shared convictions about health equity,” said Paul Farmer, MD, PhD, chief of the BWH Division of Global Health Equity and co-founder of the nonprofit Partners In Health. The Human Resources for Health Program was the result of partnerships that Farmer helped establish in Rwanda.

When the program concludes in two years, its organizers hope to see significant increases in the total number of care providers in Rwanda and bring more specialists to rural areas. By 2018, the number of physicians is expected to reach 1,182—nearly double the physician census in 2011. Organizers expect to see the number of nurses grow by about 34 percent, with the goal of reaching 11,384 nurses by 2018.

Representatives from across the HMS-affiliated hospitals involved with the program—including BWH, Massachusetts General Hospital, Boston Children’s Hospital and Dana-Farber Cancer Institute—shared milestones and challenges over the past year at the “Symposium on Rwanda Human Resources for Health Program: A Success Story of a True Partnership” on June 10.

Capping off the half-day event at HMS’ Joseph B. Martin Conference Center was a panel discussion with Farmer and Ira Magaziner, CEO and vice chairman of the Clinton Health Access Initiative. Agnes Binagwaho, MD, PhD, Rwanda’s Minister of Health, joined via video conference.

“After the 1994 genocide against the Tutsi, almost no one believed in the future of Rwanda,” Binagwaho said. “We created a future that was defined by innovation—doing what nobody expected of us—because we believed that each and every person deserves the best future.”

The HRH program aims at replacing a culture of foreign aid with one of self-sufficiency. The expectation is that greater access to high-quality health care will improve the country’s economy—whether that means ensuring children’s physical and intellectual growth isn’t stunted by malnutrition, or by creating an environment that attracts biotech companies, Magaziner said.

“What we’re aiming for is sustainability,” he said. “We want to work ourselves out of a job, ultimately.”


Emergency Medicine Fellows Assist Refugees in Greece

From BWH Bulletin 9/22/16 by Kim Hooper

For BWH International Emergency Medicine fellow Nirma D. Bustamante, MD, having the opportunity to travel to Greece to care for refugees is an experience she will always cherish.

Front row, second from left: Nirma Bustamante with other volunteers at a refugee camp in northern Greece.

“I had the privilege of caring for, and most importantly, getting to know the most incredible human beings,” said Bustamante, of the Division International Emergency Medicine and Humanitarian Programs in the Department of Emergency Medicine at BWH, which prepares leaders in global health and humanitarian response.

Earlier this month, Bustamante spent more than two weeks at a refugee camp in northern Greece, along with volunteers from Team Rubicon, which recruits, trains and deploys U.S. military veterans and health professionals to aid in disaster-response operations around the world. Bustamante provided primary and urgent care to Syrian and Iraqi refugees, developed care plans and helped patients access specialty care in the local community.

She was one of two BWH physicians who traveled to Greece via the fellowship. Over the course of the two-year program, clinicians develop skills in humanitarian aid and disaster response, emergency care systems development, health program administration and funding, human rights and more. They also must complete one emergency deployment, where they care for people forced from their homes due to a disaster or conflict. Before deploying, fellows receive specialized training in humanitarian and disaster response.

Bustamante said that while the refugees had experienced unimaginable suffering, she was struck by their positive outlook.

“Although I will be a tiny speck on their path to a better life, I, along with countless other volunteers, work every day so that this moment in time is positive and reminds them that intrinsic good still exists,” Bustamante said.

Thousands of refugees have fled to Greece to escape war and poverty, due to its close proximity to areas in crisis. Currently, 200 Syrian refugees live at the medical camp where Bustamante volunteered. The camp is expected to grow to about 800 people by the end of this year.

A former fellow herself, Stephanie Kayden, MD, MPH, chief of the Division of International Emergency Medicine and Humanitarian Programs and director of the International Emergency Medicine Fellowship, said it’s inspiring to speak with fellows once they return.

“Our fellows learn a lot about how to practice humanitarian medicine properly, as well as what happens if the job is done poorly,” Kayden said. “When they go out, they think they are going to learn new skills and become better clinicians—and they do—but I think the thing that surprises our fellows the most is how much of the care given by volunteers who lack specialized training falls short of international standards.”

Harveen Bergquist, MD, a BWH fellow who also deployed to Greece, arrived on Sept. 20 to assist the refugee camp with medical care. Bergquist says she feels a personal obligation to help others.

“I feel fortunate to have the training and departmental support to do just that,” she said. “My goal is simply to do my best to provide the quality medical care that all people deserve, while also helping to restore dignity and normalcy to people who have suffered tremendously.”


BWH physician serves as anesthesiology faculty in Rwanda

Building capacity in specialty care is key to BWH partnership with Human Resources for Health Rwanda
From BWH Bulletin 8/25/16 by Jessica Zimmerman

Training residents in anesthesiology is not only about teaching them the medicine behind the specialty, says Jill Lanahan, MD, of the BWH Department of Anesthesiology, Perioperative and Pain Medicine. It’s also about sharing a passion for the profession to inspire them to join the field.

Lanahan has done exactly that at the Brigham since March 2014, and for the next year she will share that same expertise and enthusiasm for anesthesiology with the next g16_08_25_jill_Lanahaneneration of physicians in Rwanda as part of the Human Resources for Health (HRH) Program, a collaborative, seven-year project between the Rwandan government, BWH, Harvard Medical School and more than 20 other academic institutions in the U.S. The program recently began its fifth year.

Lanahan—who relocated with her family to the Rwandan capital, Kigali, on Aug. 2—will spend one day each week doing didactic training with her new crop of residents. The other four days will consist of clinical training in the operating room. During her year-long position, she will offer three months of training in cardiac anesthesia, her primary area of clinical interest.

Although she has long had a desire to get involved in global health, Lanahan says HRH piqued her interest after chatting with two BWH colleagues in her department who were alumni of the program: Stewart Chritton, MD, PhD, and Ramon Martin, MD, PhD. She felt compelled to participate after learning just how scarce anesthesiologists are in Rwanda.

“There are fewer than 20 anesthesiologists in the whole country, and we have more than 100 in our department at the Brigham,” she said. “There’s a critical need for anesthesiologists in Rwanda.”

In Rwanda, there may only be one anesthesiologist per hospital, Lanahan explained. In addition, anesthesia is often administered by technicians—whose highest level of education is typically a high school diploma—rather than physicians or nurses, she said. In comparison, only licensed anesthesiologists and nurse anesthetists may provide anesthesia to a patient in Massachusetts.

The lack of specialized training can be deadly, Lanahan said.

“People fear anesthesia in Rwanda, and part of it is because there’s a higher morbidity and mortality rate associated with it,” she said. “By training specialists in anesthesia, we can increase the likelihood that it will be administered safely to patients.”

As part of its broader goal to build a more self-sustaining health care system in Rwanda, the program has gradually sent fewer U.S. clinicians each year to train residents.

Lanahan is one of a handful of anesthesiologists in attendance this year.

“The idea is that if a resident from a country such as Rwanda goes elsewhere to train, they might not come back to their home country,” Lanahan said. “So by bringing doctors to Rwanda, you can train them in their own environment and expand the number of physicians there.”


Combating Human Trafficking: An Interview With Hanni Marie Stoklosa, MD, MPH

Interview with Hanni Marie Stoklosa, MD, MPH

By Rachel I. Fortinsky

Dr. Hanni M. Stoklosa, MD, MPH

Hanni Marie Stoklosa, MD, MPH’s background as a BWH emergency physician has inspired her work in addressing human trafficking. She founded an organization focused on combating human trafficking. Health Education Advocacy Linkage (HEAL) Trafficking  (www.healtrafficking.org)  focuses on addressing the health-related problems that trafficked victims face from a public health standpoint. In her role as researcher, advocate, and nationally and internationally recognized expert, she has years of experience in addressing this global problem. Dr. Stoklosa has done extensive research in all areas of trafficking including sex trafficking and labor trafficking. She is a leading force in addressing the myriad of health issues which are often overlooked by health professionals, as well as a force in advocating for human trafficking legislation before the US Congress. Dr. Stoklosa has advised the US Department of Health and Human Services and was recently named an American Board of Emergency Medicine fellow (2015-2017) of the National Academy of Medicine (formerly the Institute of Medicine). She holds appointments at Harvard Medical School, the Harvard T. H. Chan School of Public Health and the Harvard Humanitarian Initiative. She has extensive international experience in many countries.  “I conducted qualitative interviews to further understand the anti-trafficking landscape and the gaps in response.” Her work has affected populations in India, Nepal, Thailand, and Kazakhstan, as well as Australia, China, Egypt, Guatemala, Liberia, the Philippines, South Sudan, and Taiwan. Most recently, Dr. Stoklosa has written a text (forthcoming, Springer Publishing in 2017) Human Trafficking Is a Public Health Issue: A Paradigm Expansion in the United States.

The US Department of State views human trafficking as a form of modern day slavery. Each year, a Trafficking in Persons (TIP) Report is generated by the Department of State. As Secretary of State John F. Kerry stated: “The TIP Report is the product of a yearlong effort requiring contributions and follow-up from employees in the United States and at our diplomatic outposts across the globe, host country governments, and civil society” (US Department of State TIP website, 2016). Overall, Dr. Stoklosa noted that she is impressed with the efforts of the Obama Administration in addressing human trafficking. She offered examples of successes and shared her optimism with the five-year federal strategic action plan. Dr. Stoklosa stated, The federal government laid out a multi-sectoral response which encourages intra-federal agency collaboration. The plan helps break down silos and create cross links to enhance responses trafficking.” President Obama also formed an advisory committee consisting of human trafficking survivors to guide federal approaches from the victims’ perspective.

In her role as a BWH Emergency Department physician, Dr. Stoklosa says the department treats approximately one to two trafficked patients weekly. Although trafficking is often viewed as an international problem in resource-limited settings, the US and the Boston area are not immune to the problem. When identified in the BWH Emergency Department often the patients can be followed in the CARE clinic which is overseen by Annie Lewis-O’Connor, PhD, RN, NP, FAAN. Identification and assessment of trafficked patients is challenging. Often patients do not think of themselves as trafficked or are reluctant to disclose information out of fear, shame or denial. Similar to those who are affected by intimate partner violence, “the focus is not on rescue, but meeting patients where they are at, and caring for their stated needs.”  She has written a paper on HIPPA and Human Trafficking which addresses the complex privacy issues in caring for trafficked individuals. An emerging health issue commonly seen in trafficked individuals is substance abuse. The widespread use of drugs, particularly heroin, among trafficked patients, as Dr. Stoklosa explained, “is because it’s either the traffickers to method of coercing them to work or the survivor’s way of coping with physical and emotional trauma.”  





Operation Walk Boston Volunteers Go the Extra Mile

Kara Burge (center), a staff nurse in Orthopaedic Surgery, with two Operation Walk Boston patients
Kara Burge (center), a staff nurse in Orthopaedic Surgery, with two Operation Walk Boston patients

A year had passed since a young man came to the clinic with severe joint disease in his hips that left him unable to stand up straight, his torso pitched forward about 45 degrees as he steadied himself on a crutch.

But thanks in part to a group of volunteer clinicians from the Brigham, he was now running laps up and down a hallway at a hospital in the Dominican Republic, where he had received bilateral hip-joint replacement surgery through Operation Walk Boston—an orthopedic medical mission founded by Thomas S. Thornhill, MD, former chair of the BWH Department of Orthopaedic Surgery.

The program partners with Hospital General de la Plaza de la Salud in Santo Domingo to perform hip- and knee-joint replacements for patients who can’t afford the procedures. It completed its ninth mission in April. Continue reading “Operation Walk Boston Volunteers Go the Extra Mile”


Emergency Medicine Bedside Ultrasound Training in Kigali, Rwanda

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Kristin Dwyer outside of CHUK Hospital

In this blog post from the Partners Center of Expertise in Global and Humanitarian Health, Kristin Dwyer, MD, MPH, a BWH fellow in Emergency Ultrasound, writes about working with emergency medicine residents for her rotation at University Central Hospital of Kigali (CHUK) in Rwanda.

“As I wrap up my time here, I must say I found it to be a valuable experience,” she writes. “While it is difficult to effect change in a short amount of time, I think having smaller goals is useful. I am not necessarily going to get patients to come to the hospital earlier in their disease course, but I can arm physicians there with ultrasound skills to more accurately diagnosis them when they arrive looking for help.” Read more.


BWH/BWFH Physicians Teach Minimally Invasive Techniques for Gynecological Surgery in Senegal

Jon Einarsson (left) and James Greenberg (right) pose with a surgeon from Senegal.
Jon Einarsson (left) and James Greenberg (right) pose with a surgeon from Senegal.

Senegal has long been one of the most stable democracies in Africa. However, compared to the United States, physicians there lack many resources. Recently, a team of Brigham physicians traveled to the country’s capital city of Dakar to teach a course in collaboration with the African Center of Excellence for Mother and Child at Cheikh Anta Diop University (also known as the University of Dakar) on minimally invasive techniques for gynecological surgery. Through a series of lectures and live surgeries, physicians taught these techniques, helping the local physicians understand how they might perform them safely with their limited resources.

Brigham and Women’s Faulkner Hospital’s Chief of Gynecology James Greenberg, MD, and Director of the Division of Minimally Invasive Gynecologic Surgery at Brigham and Women’s Hospital and BWFH surgeon Jon Einarsson, MD, were among the group of physicians conducting the week-long course organized by Senegal native and Associate Obstetrician Gynecologist at BWH Khady Diouf, MD. Continue reading “BWH/BWFH Physicians Teach Minimally Invasive Techniques for Gynecological Surgery in Senegal”


The Zika Virus in Haiti

Dr. Louise Ivers

Many questions remain about Zika and its current impact on the Haitian population. Until more answers surface, BWH and Partners In Health(PIH) staff strive to find the best solutions for women, men, and children who may be adversely affected by the virus.

Louise Ivers, MD, MPH, of the BWH Division of Global Health Equity and senior health and policy advisor for PIH, answers questions about the mosquito’s resiliency, efforts to control it in Haiti and how PIH is working to prevent Zika infections and treat those who might be suffering from complications.

Read the Q&A on the PIH blog.


MRCT Center Takes on Emerging Issues in Global Clinical Trials


MRCT Center staff include, from left, Heather Marino, program manager; Barbara Bierer, faculty co-director; Rebecca Li, executive director; Mark Barnes, faculty co-director; and Carmen Aldinger, program manager.

When Indian regulators implemented a series of new clinical trial regulations in 2013, clinical trials in India ground to a halt. Under the new regulations, clinical trial sponsors would be responsible for compensating participants who were injured or died during the trial, even if the death or injury was unrelated to the trial itself. Virtually all clinical trials sponsors, including the National Institutes of Health, stopped initiating any new trials. Less than two percent of the world’s clinical trials were unfolding in a country that is home to one-seventh of the world’s population. Barbara Bierer, MD, co-director of the Multi-Regional Clinical Trials (MRCT) Center, had been following the dilemma in India closely.

Bierer and Mark Barnes, then at Harvard University, had launched the MRCT Center in 2011 to define and address emerging issues in global clinical trials. By bringing together a variety of stakeholders, the center aims to find solutions to improve the integrity, safety and rigor of trials around the world.

After the new regulations were announced, Bierer and her colleagues reached out to government officials and industry and academic stakeholders in India, organized roundtable discussions and, over the course of more than 14 visits to the country, worked closely with Indian leaders to help to develop fair amendments to the earlier legislation and address the issues resulting from regulatory reform. The MRCT Center has been involved in training, and in developing scalable tools that will assist the appropriate application of the regulations such as a tool to assess causality to determine whether a death or injury is directly linked to a clinical trial. Their efforts continue today.

Read the full story in the February issue of BWH Clinical & Research News.


Training the First Generation of Neurologists in Haiti

Aaron Berkowitz teaches a neurology course to residents in Haiti.

Haiti has just one neurologist for 10 million citizens, but the burden of neurological disease there is enormous, say BWH’s Aaron Berkowitz, MD, PhD, and Louine Martineau, MD, of the University Hospital in Mirebalais, Haiti.

Since BWH helped the University Hospital open in 2013, Martineau has been regularly consulting on his neurologic patients with Berkowitz, who leads BWH’s Global Neurology Program. “By opening an outpatient clinic in communication with Dr. Berkowitz, we have created a way to manage patients with neurologic problems,” says Martineau.

To address the larger problem, Berkowitz and colleagues are launching Haiti’s first neurology training program. Initial seed funding will allow them to train two neurologists over the next two years.

“With further investment in the fellowship, we hope to train a few neurologists every year,” says Berkowitz. “These neurologists will serve different regions of the country so patients can get the care they need from local providers.”

Read the full story in the Brigham and Women’s magazine (pages 24 and 25).