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.
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 firstname.lastname@example.org.
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.
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.
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.
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.
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.”
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.
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.
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.
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.
“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”→
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>>
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”→