Mission Moment: Supporting Novel Approaches to Reducing Inequities

Reprinted from Dr. Betsy Nabel’s BWH President’s Perspective 28 February 2019 and
BWH Awards and Honors 22 February 2019

For so many of our most vulnerable patients, it’s clear that addressing large-scale inequities requires a disruption of the status quo. Members of our Brigham community are doing just that as they work to resolve some of the root causes of insufficient care among underserved populations, with support from the Department of Medicine’s new Health Equity Innovation Grants Program.  The seven recipients of the department’s inaugural Health Equity Innovation Grants are leading projects designed to advance health justice for a diverse group of patient populations and develop solutions for addressing barriers they face in accessing care.  One project, for example, aims to create best practices for collecting information on a patient’s history of incarceration. Another will focus on addressing racial, ethnic and socioeconomic disparities in lupus care. 

In the words of Joe Loscalzo, MD, our chair of Medicine, “An equity lens allows us to improve care for all our patients. With this belief in mind, the department is committed to an honest appraisal of care and a willingness to imagine a care improvement strategy that addresses factors leading to disadvantage, including race, age, gender, post-incarceration status, experience of trauma and others.”

Spearheaded by the department’s Health Equity Committee, the goal of the HIEP is to engage and support population-based research or program implementation that measures and addresses care inequities. Selected projects are action-oriented — aimed at supporting meaningful measurement and evaluation of existing patient care inequities and rapidly developing responses to improve quality and effectiveness of care for the most marginalized patients. While based in Department of Medicine, most projects cross divisions and departments; several may serve as pilots for potential hospital-wide improvement.

The grant recipients and winning projects are:
Rob Boxer, MD, PhD, Division of Internal Medicine: “Reducing Structural Inequities in Heart Failure Management: An Approach to Improve the Quality of Heart Failure Care on the General Medicine Service”
Candace Feldman, MD, ScD, Division of Rheumatology, Immunology and Allergy: “Addressing Racial, Ethnic and Socioeconomic Disparities in Lupus Care Through an Integrated Care Management Program Pilot”
Laura Frain, MD, MPH, Division of Aging: “Targeted Geriatric ‘No-Show’ Home Visits for High-Risk, Vulnerable Older Patients in the Phyllis Jen Center for Primary Care”
Monik Jimenez, PhD, Division of Women’s Health: “Developing Best Practices to Collect Information on Past History of Incarceration”
Annie Lewis-O’Connor, PhD, MPH, NP-BC, Division of Women’s Health: “Advancing Trauma-Informed Education into Clinical Practice for Adults: A Curriculum for the Hospital Staff”
Evan Shannon, MD, MPH, Division of General Internal Medicine and Primary Care: “Racial Disparities in Inter-hospital Transfer”
Bram Wispelwey, MD, MPH, Division of General Internal Medicine and Primary Care: “Reducing Structural Inequities in Heart Failure Management: Understanding and Addressing the Drivers of Admission Service Decisions”

The Health Equity Committee was chartered in 2017 by Joseph Loscalzo, MD, chair of Medicine and physician-in-chief, with the vision of advancing the department’s commitment to health equity by engaging key internal and external stakeholders in a structural analysis to address health inequities in the department and community, which will inform and influence hospital-level strategy. The committee is co-chaired by Michelle Morse, MD, MPH, assistant program director of the Internal Medicine Residency Program and associate physician in the Division of Global Health Equity, and Tom Kieffer, executive director of Southern Jamaica Plain Health Center and Jennifer Goldsmith, Director of Administration in the Division of Global Health Equity, serving as implementation partner.

Under the Same Sun: Helping Others Locally and Globally

Reposted from Brigham Clinical & Research News
By Abaraar Karan, MD, MPH
25 February 2019

Marshall Wolf (left) and Abraar Karan (right)

Next Generation is a Brigham Clinical & Research News (CRN) column penned by students, residents, fellows and postdocs. This column is written by Abraar Karan, MD, MPH, a second-year resident in the Department of Medicine and the Doris and Howard Hiatt Residency in Global Health Equity. He was recently named a 2018 40 Under 40 Healthcare Innovator by MedTech Boston, as well as a 2018 STAT News Wunderkind. If you are a Brigham trainee interested in contributing a column, please email bwhclinicalandresearchnews@partners.org.

As a child, I remember summer trips to Hyderabad, India—the city where I was born but had only spent a few months living before moving to the U.S. More than the sweltering heat and buzzing mosquitos, I remember the human suffering. It was hard not to—people in search of money and food would constantly tap at the window of our car while we were stuck in bustling traffic. They would tug at my pants to get my attention as I walked by while holding my parents’ hands. They were visible, yet invisible—almost like we were in two different worlds. But I knew we were not. They were sweating just like I was, under the same unforgiving sun. They were hungry like I was, but they didn’t have food most of the time. Their plight was unforgettable, at least to me.

Twenty years later, I found myself in the office of Marshall Wolf, MD, emeritus vice chairman for medical education at the Brigham, interviewing for a spot in the hospital’s categorical Internal Medicine Residency. Unlike most interviews, the one with Dr. Wolf was not about board exams or clinical rotations; Dr. Wolf asked me where I wanted to be in the future and what that future looked like for me. Now a second-year Internal Medicine resident at the Brigham, I have been supported from day one by Dr. Wolf and my global health mentors, including Joseph Rhatigan, Jr. MD, the associate chief of the Division of Global Health Equity; Paul Farmer, MD, PhD, chief of the Division of Global Health Equity; and Ingrid Katz, MD, associate director of the Harvard Global Health Institute, in every endeavor, local and global, to make sure that future comes sooner. The Brigham is special in this way. The people here care about your success on a personal level. I try to meet with Dr. Wolf every few months to check in and seek his advice on clinical and non-clinical matters—and I always find myself learning something new through his unmatched experience and wisdom.

Pursuing Global Public Health

Between my childhood trips to India and my eventual match at the Brigham, I had the privilege of working in nearly a dozen countries in many remote regions of the world. Several of my projects were in rural villages—some in India, others in Central America and Sub-Saharan Africa. Despite country-specific differences, abject poverty and ill health were unmistakably linked. You cannot sustainably improve one without addressing the other. While medicine can certainly treat symptoms of illness, it alone cannot treat the root causes of illnesses. But public health may be able to, which inspired me to pursue a career in both clinical medicine and public health and earn an MPH degree at the Harvard T.H. Chan School of Public Health prior to beginning my residency.

Today, my work is focused on addressing social, political and ethical factors that plague global health systems and hamper innovation in impoverished regions. For example, I have written about the ethical challenges of caring for women in sex trafficking—a community with whom I spent a year working in the villages of India. Additionally, I worked with the Centers for Disease Control and Prevention in Mozambique, where I wrote about the role of communication among high-profile political officials in combating the HIV epidemic. I also published a book, Protecting the Health of the Poor: Social Movements in the South, which examines the role of global, grassroots social movements that led to improved health outcomes in low- and middle-income countries.

Creating Opportunity for Others

To help improve public health, my college roommate and I have been working to develop the world’s safest, longest-lasting and most effective mosquito repellent to address insect-borne illnesses. We co-founded a company called Hour 72+, which produces a non-DEET (diethyl-meta-toluamide) repellent that uses patented polymer technology to exponentially increase the longevity of repellency with a single use. Recently, we won first place at the Harvard Business School’s 2018 New Venture Competition and are currently in discussions with large public health agencies about deploying the repellent for international field testing.

I am also closely following the emerging Ebola epidemic in the Democratic Republic of the Congo and working with mentors from the Harvard Global Health Institute to write about epidemic-response strategy. I am hoping to spend upcoming months working in Sub-Saharan Africa on epidemic response with a government agency.

For many years, my motivation has been linked to a simple idea: Where you live should not determine if you live. I was lucky when I left India as a child—I had the privilege of opportunity and the guidance of a loving family and mentors. Without them, I wouldn’t be here. But for many others, I know this is not the case. I have taken care of men my age who died needlessly of preventable and treatable illnesses, such as malaria and HIV, largely because they were poor and powerless. This is not the type of world I want to live in, and I plan to change it in the small ways that I can.

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BWH Launches Global Health Hospital Medicine track

Dr. Peter Rohloff developed the new BWH Global Health Hospital Medicine track.

Peter Rohloff, MD, PhD is a BWH hospital medicine physician, an NIH-funded researcher, and the founder the highly impactful NGO, Maya Health Alliance,  in rural Guatemala. Dr. Rohloff is not alone among BWH physicians who strive to improve the world within our walls and beyond. Yet he is also committed to expanding opportunities for others to be a part of both BWH and the global health community. In 2017, Dr. Rohloff established a global health track for hospital medicine physicians to allow them  flexibility to practice at BWH and to work globally while enhancing their experience with significant global health mentorship and community.

BWH Global Health track Hospitalist Dr. Bram Wispelwey trains community health workers in refugee camps in Palestine.

The first cohort of Global Health track physicians in Hospital Medicine began at BWH in July 2018, each with an individual global focus. Among the three  is Bram Wispelwey, MD, MS. Dr. Wispelwey completed the BWH Doris and Howard Hiatt Global Health Equity Residency in 2018 and stayed on in this newly created role. When not at BWH, Dr. Wispelwey  is working to mend the fractured healthcare system within Palestinian refugee camps.  These camps do not have dedicated local clinics or consistent access to basic affordable primary care. To address these complex issues, Dr. Wispelwey helped launch and monitor a Community Health Worker program to improve relationships and rebuild trust between doctors and patients, strengthen the healthcare delivery system, and ultimately improve the health of refugee families. He now divides his time between the camps in Palestine and Boston.

Jennifer Goldsmith, Administrative Director of the Division of Global Health Equity helped establish the partnership between BWH Hospital Medicine and the Division of Global Health Equity. She describes the global health model, “the track is highly customizable to meet the needs and interests of individuals and offers opportunities for global health research and field work, didactics, and career mentorship. We’re delighted to build on the mentorship and global health opportunities in our Division creating this new career step.”

According to Dr. Rohloff, “the vision for this track is to help junior faculty with a strong interest in global health to take the next steps in advancing their global health careers, through making connections to the excellent mentorship and development opportunities available at Brigham and Women’s Hospital and finding a clinical home here, as well.”

Applications for 2019 are now open. Read the job posting.

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.

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

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.”

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

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.

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

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.
Continue reading “BWH researchers discover global healthcare investment leads to state stability”

‘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.
Continue reading “Dr. Mukherjee’s New Textbook Will Reshape How We Teach Global Health Delivery”