Doris and Howard Hiatt Residency in Global Health Equity and Internal Medicine: from training incubator to global impact

Drs. Paul Farmer, Howard Hiatt, and Joe Rhatigan with alumni of the Hiatt Residency in Global Health Equity.

With a commitment to increasing the number of physicians who aim to dedicate their careers to improving the health of impoverished people in the U.S. and abroad, the division, the Department of Medicine (DOM), and BWH created a unique residency program to address this growing interest. In 2004, the Doris and Howard Hiatt Residency in Global Health Equity and Internal Medicine was established as a comprehensive program that includes training in internal medicine; coursework in research methods, public policy, global health advocacy; and research and patient-care experiences in impoverished settings at PIH sites around the world. The program adds an additional training year to Internal Medicine and Internal Medicine and Pediatrics residencies and residents earn an MPH as part of the program. The residency program honors division co-founder Dr. Howard Hiatt and his late wife, Doris.

The Hiatt GHE residency acts as an incubator, providing young physicians with the resources necessary to explore many different possible paths in global health. That support continues long after residents have graduated from the program. Because global health equity remains a pioneering field, former residents continue to define for themselves what it means to have a career in global health—often connecting with other graduates in the process. This networking is a natural outgrowth of the Hiatt GHE residency, which many involved describe as a family that extends around the globe. The program’s focus on learning and mentorship encourages residents to reach out to previous graduates working in the field for support, guidance, and collaboration.

The impact of the Hiatt residency program goes far beyond the outstanding individual trainees themselves.  Hiatt residents go on to train hundreds more physicians and health workers, creating a multiplier effect from the initial investment in the program. Residents are empowered to share their knowledge and support the development of healthcare infrastructure that pays increasing dividends over time.

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BWH’s Aaron Berkowitz wins Mridha Spirit of Neurology Humanitarian Award, envisions expanding specialty training programs in resource limited settings

Aaron Berkowitz, MD, PhD, was recently awarded the Mridha Spirit of Neurology Humanitarian Award from the American Brain Foundation and American Academy of Neurology for his work to expand access to neurology education and clinical care in resource-limited regions of the world. This award recognizes his tireless efforts developing Neurology training in Haiti. Over six years, Dr. Berkowitz has grown from a visiting professor to an architect of expanded neurology care with a vision for development of specialty training programs globally.

Dr. Aaron Berkowitz and inaugural Haiti Neurology Fellow Dr. Roosevelt François.

Knowing there was a dire shortage of neurology support in Haiti, in 2012, Dr. Aaron Berkowitz reached out to his colleague Dr. Michelle Morse. Dr. Morse of the BWH Division of Global Health Equity and a founder of EqualHealth explained that there was just one neurologist for the entire population of 10 million people in Haiti which contrasts starkly to 76 neurologists per 100,000 people in Boston. In Haiti, the vast majority of patients had no access to a neurologist for care and most general practitioners had no access to a neurologist to learn from.

In response to this grave inequity, Dr. Berkowitz began working in Haiti with Partners In Health and EqualHealth teaching Continuing Medical Education courses in neurology for internal medicine and family medicine staff and trainees.

Yet, after several years, Dr. Berkowitz started to feel spread thin- he would give lectures to large groups, and see consults with individual doctors in several departments in two different hospitals on each trip. “It seemed like we could have more impact if we focused on training a smaller group over a longer period instead of a ‘neurology for all’ approach,” says Berkowitz. A team including Dr. Berkowitz, Dr. Morse and colleagues at Hôpital Universitaire de Mirebalais (HUM), developed an intensive neurology rotation for HUM internal medicine residents. Through this program, Berkowitz spent four 1-week trips to Haiti working directly with the same five residents who were released from all other responsibilities.

“Where specialists are trained, they can educate their primary care colleagues, increasing their capacity to care for patients with diseases requiring specialty referral.”

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Rwanda’s University of Global Health Equity partners with BWH faculty member Michelle Morse, MD, MPH

When Dr. Paul Farmer, Division of Global Health Equity Chief and Co-Founder and Chief-Strategist of PIH, began his work in some of the world’s most marginalized regions, he realized quickly that the traditional scope of health care did not and could not apply. Without consideration of the cultures, the geopolitical structures, and the intrinsic ties between poverty and health, one could not begin to properly offer quality care or address the even greater systemic challenges at work. Expanding his vision for system strengthening, Dr. Farmer helped to found the University of Global Health Equity in Rwanda. to educate the next generation of global health professionals—doctors, nurses, researchers, and public health and policy experts—into leaders and changemakers who strive to deliver more equitable, quality health services for all.

Dr. Michelle Morse teaching an HUM resident best techniques for using and interpreting portable ultrasound equipment.

Globally, the pipeline of future doctors, nurses and global health leaders is far too limited. Top health and medical programs around the world  attract a narrow group of students who often end up leaving their underserved communities or countries to practice in urban centers or abroad. But simply training more doctors and nurses isn’t enough. The global health education system is failing to prepare students to solve our most pressing health challenges— from containing new diseases like Ebola and stemming the rapid rise of noncommunicable diseases to designing and running health care systems. To solve these challenges, global health leaders including Dr. Farmer and DGHE faculty must reimagine global health education; UGHE is doing just that.Dr. Michelle Morse has committed her decade long career to building disruptive pedagogy and medical education systems in countries from Haiti to Rwanda to the U.S. Trained in internal medicine and public health, Dr. Morse teaches at Brigham and Women’s Hospital, Harvard Medical School, the University of Global Health Equity (UGHE), and the organization she co-founded, EqualHealth. As Visiting Faculty at UGHE, Dr. Morse teaches in the foundational Principles of Global Health Equity course in the Master of Science in Global Health Delivery (MGHD) program. Through her work with EqualHealth, an NGO that aims to inspire and support the development of Haiti’s next generation of health care leaders, Dr. Morse is course director for a social medicine immersion course which has been held every July in Haiti since 2013.

Below, is UGHE’s  interview with Dr. Morse about radicalizing training in global health by pioneering a curriculum focused on equity.

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BWH researchers discover global healthcare investment leads to state stability

Jennifer Goldsmith, Division of Global Health Equity

How much does the US government spend on foreign aid and what is the impact of that support? This question has taken on new urgency with the current administration’s proposals to dramatically reduce foreign spending. BWH researchers have taken the question of the impact of foreign health aid with results that should inform critical policy decisions around allocation.

BWH researchers, led by Dr. Vinay Gupta, of BWH Division of Pulmonary and Critical Care Medicine,  have studied the impact of US aid in healthcare on stabilizing fragile economies and found that in Sub-Saharan countries US health investments not only improve population health outcomes, but strengthen governance indices contemporaneously.  Dr. Vin Gupta and his colleagues published their findings in Global Public Health on March 14, 2018. Their results demonstrated a novel finding:  US health aid leads to immediate improvements in metrics of state stability across sub-Saharan Africa.

The Council on Foreign Relations, an independent, nonpartisan  think tank, estimates that foreign aid accounted for roughly 1.3 percent of the federal budget in 2015 ($49 billion). Through another lens, the US spends 0.17 percent of GDP, twentieth out of twenty-eight countries measured by the Organization for Economic Cooperation and Development (OECD). Sweden, Norway, Luxembourg, Denmark, the Netherlands, and the United Kingdom all spend more than 0.7 percent of GDP on foreign aid, which is the target set by the United Nations.
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‘An Unbreakable Bond’: BWHers Partner with Indian Health Service Providers

Originally published in BWH Bulletin 11/30/17

For several BWHers, including Srini Mukundan, MD, PhD, of the Department of Radiology, being able to work with care providers at Northern Navajo Medical Center in Shiprock, N.M., and Gallup Indian Medical Center in Gallup, N.M., through the Brigham and Women’s Outreach Program with Indian Health Service (IHS) has been an educational and transformative experience they will always cherish.

Mukundan, who has trained IHS staff on-site in Shiprock and remotely from BWH, said his experiences with the program provide an antidote to burnout and remind him why he chose this path in medicine.

BWH’s Srini Mukundan and IHS Staff Radiologist Brian Demby in front of CT scanner at IHS Shiprock

“The Outreach Program opportunities have been one of the greatest rewards of being a BWHer,” Mukundan said. “After meeting the wonderful patients and witnessing firsthand the work of our remarkable colleagues at Shiprock, it is clear how important the essence of the physician-patient relationship is, especially in light of the limited resources available in Shiprock.”

Since 2009, BWHers have collaborated with the Navajo Area IHS – the federal agency responsible for delivering medical and public health services to members of federally recognized Native American tribes in the region. Through the Brigham and Women’s Outreach Program with IHS, BWH faculty, nurses, trainees and other providers volunteer their time and expertise to provide specialized care and training – on the ground at IHS hospitals and through remote teaching – in rural New Mexico and Arizona. Continue reading “‘An Unbreakable Bond’: BWHers Partner with Indian Health Service Providers”

Guest Blog: Renewed activism, not budget cuts, needed to end the AIDS epidemic

Dr. Joia Mukherjee is an associate professor in the Division of Global Health Equity at Brigham and Women’s Hospital, and she has served as the Chief Medical Officer for Partners in Health since 2000. She recently published an undergraduate textbook titled, “An Introduction to Global Health Delivery.” This 12/21/17 blog post is from the Oxford University Press blog.

Policy makers, organization, and governments have worked side-by-side with people living with AIDS as part of a global social movement for three decades. The success of the movement for HIV treatment access not only garnered billions of dollars of new money for HIV treatment, but also served to shift the public health paradigm from prevention-only to the provision long-term treatment. This paradigm shift ushered in a new era in global health. One that has strengthened health systems and treated a variety of conditions from non-communicable diseases, women’s health, mental illness, and cancer. Stronger and more resilient health systems are the result. Adult, child, and maternal mortality have dropped in many of the world’s poorest countries. UNAIDS recently announced that as of 2017, 21 million people have received antiretroviral therapy—the life-saving medications that have transformed AIDS from a fatal disease to a manageable and treatable one. READ MORE>>

Dr. Mukherjee’s New Textbook Will Reshape How We Teach Global Health Delivery

Brittany Stopa is a Clinical Research Regulatory Coordinator in the BWH Department of Neurosurgery, and holds a Masters of Public Health in Global Health. She is a contributor to the BWH Global Health Hub.

Dr. Joia Mukherjee is an associate professor in the Division of Global Health Equity at Brigham and Women’s Hospital, and she has served as the Chief Medical Officer for Partners in Health since 2000. She recently published an undergraduate textbook titled, “An Introduction to Global Health Delivery.”

“In stunned silence I watched Lovely die in front of me. Her bloated belly, red hair, and swollen feet screamed the medical diagnosis kwashiorkor, protein calorie malnutrition, starvation. The heartache, anguish, and even shame on her mother’s face pierced my psyche… Children do not die of starvation because of their mothers’ ignorance. Mothers know when their children are hungry from their ceaseless cries. They know when their children are dying of starvation when the crying stops. More than 25 years ago I first witnessed death from starvation. In my youth, my ignorance, and my relative solitude, I delivered only the prescribed guidance to Cynthia, and to other mothers. But I could not make sense of a world where a starving child was not offered food. I felt ashamed then and now at the gross inequity of a world with enormous wealth and starving children. Health disparities are a thermometer of injustice.”

This introduction to Mukherjee’s new textbook from Oxford University Press, An Introduction to Global Health Delivery, sets the tone for a publication that aims to reshape the field of global health and how it is taught. In it, she calls out the established set of practices in global health as failing the people they purport to serve. And Dr. Mukherjee calls for a new approach to global health delivery, one that is built on the premise that everyone has a right to health.
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Dr. Gupta is Shifting Healthcare Systems in Resource-Poor Settings to Address NCDs

Dr. Neil Gupta, BWH Division of Global Health Equity.

By: Brittany Stopa

Ms. Stopa is a Clinical Research Regulatory Coordinator in the BWH Department of Neurosurgery, and holds a Masters of Public Health in Global Health. She is a contributor to the BWH Global Health Hub.

Dr. Neil Gupta is a physician in Brigham and Women’s Division of Global Health Equity (DGHE) who is working to strengthen healthcare systems by addressing the growing problem of noncommunicable diseases in low-income countries. I sat down with Dr. Gupta to discuss the scope of his work and the landscape in which he conducts these critical system-strengthening efforts.

Ms. Stopa:       Thank you for joining me, Dr. Gupta. I want to talk to you today about noncommunicable diseases (NCDs) and your work in addressing them. I read in the World Health Organization (WHO) report in 2015 that 70% of the world’s 56 million deaths were caused by NCDs1. And so, as somebody that works in that field, do you see NCDs emerging as the focus of public health? Is this the direction the field is moving?

Dr. Gupta:       NCDs are definitely an emerging focus in global health and are increasingly recognized as a critical issue that we need to address. NCDs, to give you an overview, are a diverse group of chronic illnesses that include cardiac conditions, cancers, respiratory diseases, diabetes, blood disorders, kidney diseases, liver cirrhosis, congenital diseases, and many other conditions. It can also include mental disorders and injuries, which may require surgical, rehabilitation, or palliative care services.

In the global health community, NCDs are set apart from more traditional infectious diseases, which have historically been a major focus in global health. Infectious diseases cause a huge number of deaths, but luckily many can now be prevented or treated with adequate tools and resources. Addressing large-scale infectious epidemics, as well as basic maternal and child health services, was the first goal of emerging health systems in lower income countries globally. But now, as health systems and coverage of health services have improved in those areas, the area of NCDs is being increasingly recognized as the next step for maturing health systems.

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Better Counting Preterm Babies: BWH authors’ new review examines what works, and what’s next globally

Anne CC Lee, Lian Folger, Lauren Schaeffer, Pratik Panchal, Hannah Blencowe, Joy E Lawn
Nov 17, 2017 is World Prematurity Day. The authors publication on diagnostic accuracy in neonatal assessment was released today in Pediatrics.

On World Prematurity Day, findings from a new study will be published in the journal Pediatrics.1 This systematic review examines the accuracy of different newborn assessments to determine gestational age and identify preterm babies.

WHY THE EARLY IDENTIFICATION OF PRETERM BABIES IS IMPORTANT

Each year, 15 million babies are estimated to be born preterm (before 37 completed weeks gestation), with the vast majority born in low- and middle-income countries (LMICs).2 Preterm birth complications are the leading cause of under-5 child mortality globally3—accounting for 1 million neonatal deaths each year.4

Preterm babies are more likely to die in infancy or become ill with conditions that could be effectively treated if identified early, such as breathing problems, infections, or low body temperature.   The early identification of preterm babies enables health workers to offer these babies special care, including better monitoring and the timely delivery of potentially life-saving interventions, such as continuous positive airway pressure or kangaroo mother care. Furthermore, accurate determination of gestational age is needed to identify growth-restricted infants, who also carry increased risk of mortality and morbidity in infancy and beyond.

In order to save lives of premature and growth-restricted infants in LMICs, these high-risk infants need to be accurately identified as early as possible and targeted for interventions.
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BWH Global Health Equity faculty and PIH colleagues unveil toolkits for costing and mentored quality improvement in resource limited settings

The original version of the article was posted by Partners in Health

In 2009, BWH faculty in the Division of Global Health Equity began a journey with colleagues in Rwanda, at Partners In Health and at HMS, to strengthen community health across the globe. That journey culminated this fall, with the publication of dynamic toolkits on MESH-QI and District Costing Methodology that will allow the impact of this work to endure. Funded by the Doris Duke Charitable Foundation’s Africa Health Initiative, this ambitious work is coming to a successful conclusion and culminating with numerous publications, notably including two powerful toolkits that will allow this work to be replicated at many sites for years to come.

Dr. Lisa Hirschhorn and Dr. Peter Drobac were principal investigators on the Population Health Implementation Training project, which sought to make significant improvements to WHO health system building blocks. The project also worked to fulfill MOH priorities such as improving the quality of health center-based care, strengthening monitoring and evaluation, and enhancing community health worker networks.

Out of this grant and the vision of these leaders, Partners In Health has developed a model for mentoring health care workers. The model is gaining broad attention after improving quality of care in Rwanda and elsewhere for several years. The team also has developed a new guideline—along with a separate, cost-analysis toolkit—that describes how health centers and systems can implement the model, combat the global shortage of quality health care staffing and plan budgets across a range of services.

“Building a culture of high-quality care delivery processes and systems is almost impossible, especially in resource-limited settings,” said Anatole Manzi, director of clinical practice and quality improvement for PIH, who worked closely with Drs. Hirschhorn and Drobac on this project.

“This guide provides invaluable help to organizations and governments preparing to implement MESH-QI as a model for Health Systems Strengthening,” Anatole Manzi, director of clinical practice and quality improvement for PIH.

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