Global Health eMagazine NUVANCE HEALTH AND THE UNIVERSITY OF VERMONT LARNER COLLEGE OF MEDICINE

Our Global Health experience would not be remotely as special or memorable without a very special young lady named Philista. Philista is the young woman who helped guide our stay at Naggalama hospital in Uganda. She runs the guest house for all visitors who pass by. Anything we wanted to learn, see, do, eat, Philista was there to help make it a reality. Everyday was a new excursion with her.

Philista’s voracious appetite to explore and learn new things was infectious and made our exploration of Uganda one hilarious roller coaster ride we cherish. She didn’t know how to swim yet took the leap to go rafting on the Nile with us! Weekly grocery runs became mini concerts as we played music and sang on the back of boda bodas (motorcycles) under the african sky. She protected and guided us as we made our shopping trips for the Go Fund Me project, making sure her muzungus got value for their buck.

When we felt weak from a long day in OR or wards, she would have our favorite snacks and foods ready. When we were sad over the patient we lost and tears streamed down our faces, she somehow knew exactly what to say to make us start laughing.

After countless hours of getting to know just each other’s worlds, hopes and dreams, we knew without a doubt Philista is meant to travel and explore the world. She opened up about her dreams, one of which is to continue her education and finish college majoring in Tourism. Philista is now taking the steps to sign up and continue her education which ultimately would allow her to apply for her dream job, an airline stewardess, and make her dreams of seeing the world a reality. In our last week, we started the process of making sure Philista got her passport and it is indeed in the works!

Philista educated us about Uganda and helped us navigate our way, but what Philista doesn’t know is that she taught us beyond that. She showed that no matter where in the world you come from, whatever you’ve experienced, the differences dissipate and the similarities in spirit and love predominate. And without a doubt, we would go back to Naggalama, just to visit our sister, Philista.

Reflections

Reflecting on My Global Health Journey During Medical School

Written by Jett Choquette, MD, Class 2023

Near graduation (May 21, 2023) from the Larner College of Medicine at Vermont University, I find myself reflecting on the role global health played throughout my medical school career. Soon I will start a new adventure, internal medicine residency at Virginia Commonwealth University (VCU) in Richmond, VA. As I reflect on the large role global health has played in my life so far, I’m also curious how it will continue to be part of my training at VCU.

I started medical school knowing I wanted to be part of global health, but I was still formulating what that meant to me. I’d been a community health volunteer in the Peace Corps in Paraguay prior to starting medical school. From my time in the Peace Corps, I knew several things: I wanted to be based in the US, I believed in equal partnership, and (when I worked abroad) I ultimately hoped to develop a long-term relationship with one community to which I’d return over the years.

The Nuvance/LCOM Global Health Program welcomed me as I started my first year of medical school. I was set to go to the Dominican Republic (DR) the summer after my first year of medical school, something I couldn’t have been more excited about. I couldn’t wait to see what global health from the medicine perspective was like as the Peace Corps had already given me a glimpse of global health from the public health perspective. Then COVID came and everything changed.

My trip to the DR was canceled. Further no one, new or seasoned, in global health could travel easily as the COVID pandemic raged. The leaders in global health around me, who had previously looked abroad, looked inward to their local communities as they could no longer travel. Was it possible to address global health on a local level?

I helped with flu clinics for migrant workers in Vermont. I took part in early discussions and projects of the UVMMC Emergency Department Diversity, Equity, and Inclusion Committee as part of the New American Subcommittee. I helped develop longitudinal global health curriculum to be included as part of the LCOM regular curriculum. I found a community in the Global Health Program, but still hadn’t found a project that blended my love of health and Spanish in the way I hoped.

I moved to Connecticut for my clinical years of training (years three and four of medical school), as a member of the LCOM Connecticut campus 2023 class cohort. Dr. Sadigh connected me with Elvis Novas, a leader of the Dominican Community Center (DCC) in Danbury, CT. The DCC is a non-profit that seeks to empower the Dominican community and other Hispanic/Latinx/Latino communities in the Danbury, CT area. Working together over the past two years, the DCC and I built a partnership between the Latinx community and the Global Health Program. As part of this partnership, we designed projects to promote health literacy.

I was grateful for the kind welcome and dedication of the DCC members as our partnership blossomed. Earlier this spring, a new third year medical student took over my role as the Community Liaison from the Global Health Program to the DCC, as my graduation was looming. The DCC is currently planning a summer youth leadership academy that will include a health literacy component.

Despite the unexpected twist the COVID pandemic caused in my global health journey, I ultimately found my medical school global health home in Danbury, CT working with the DCC. The opportunity to collaborate with an important population within the community where I was training as a medical student resonated with me as especially important. I was glad that the Global Health Program was prioritizing local global health efforts.

The importance of empowering Latinx people within the Danbury, CT healthcare system became more evident the more time I spent in the clinic and hospital. Nuvance serves many Spanish and Brazil-Portuguese speaking patients. Danbury, CT has a diverse medical community with many doctors, nurses, and other healthcare professionals who are native Spanish or Portuguese speakers – yet the challenges of communication across cultures and languages remains for many healthcare professionals (including myself) where Spanish and/or Portuguese are second languages. The challenge of using phone interpreters can delay care. It can cause confusion. Partnering with the local community, such as the DCC, gives the Global Health Program an opportunity to address the challenge of providing healthcare locally to people from all around the world.

Partnerships like the DCC-Global Health Program allow our local health system to better learn from and involve local communities in health care improvement. It allows us to open a channel of communication where the exchange of ideas can flow both ways and the end goal of improving health for all becomes a mission that both the health system and the community own. I’ve been honored to take part in the development of the DCC-Global Health Program partnership. And while I’m no longer the medical student on the ground helping the DCC, I remain connected to the DCC community. I can’t wait to see how our Danbury community continues to grow and evolve in the future.

Week 2 and 3 Reflections

Written by Asima Mian, PGY3 resident

CIFC Health Primary Care Internal Medicine Residency Program

It has been quite busy the past few weeks with finishing up work at the hospital and coordinating all the donation items for the school. There is an ortho camp doing pro bono hip and knee arthroplasties for the past 10 days. I scrubbed into several ortho procedures to help out, covered the gen med ward and anywhere else I could be helpful. At the end of week 1 we went on an African Safari which was incredible! I spent time on the maternity ward and maternal ultrasound. I learned that rather than cost of care, cultural practices and medical myths are what deter people from seeking health care. Many pregnant women did not seek any prenatal care due to cultural beliefs and myths. They fear that the ultrasound would harm the fetus. They also had personal fears of knowing their HIV status and would rather not know their status and would therefore not get tested. Most of the cultural beliefs occur in the village tribes. It was a challenge to educate these women given their strong personal and cultural beliefs however some women were very interested in learning about prenatal care.

Near the end of week 3 was the end of Ramadan and Eid. We attended Eid prayer at the local Mosque then traveled to Kampala for the weekend. Eid is a public holiday here and celebrated for 3 days. It was so fascinating to see the entire country celebrate Eid which is a Muslim holiday in a non-Muslim country. One thing I have noticed is that there is a wide acceptance of different religions and the freedom to practice religion in peace without oppression. Everyone is very accommodating and welcoming towards each other’s faith. It is very heartwarming to see such kindness towards each other in this regard. When visiting Kampala, we went to the royal palace and parliament and learned about the history of Uganda’s independence. It took years of civil unrest and conflict before achieving a state of freedom of religion and peace.

Week 1 in Vietnam Reflection

Written by Olivia Warren

American University of the Caribbean School of Medicine, Class of 2023

I am sitting in my hotel room, with the window open, hearing the birds chirp, smelling the air and seeing the hospital from my window. My first week in Saigon has been fascinating and overwhelming at the same time. The city moves at a very quick pace, with a constant fluid movement of people going from one place to another. The unceasing of cars, scooters and people on-the-go is something that is unusual for me. I grew up in a quiet town in Orlando, where the streets and shops are closed and quiet after a certain hour; this is most definitely a shift in pace. I am handling it well though being that I have always been appreciative to see how other cultures exist in their respective countries. I think the most interesting thing I have seen thus far is how authentic Vietnam is. The people, the food and how people live here is very different. For example, I commonly see how families eat together and all eat the same meal during lunches and dinners. Common dishes include noodles, rice and vegetables, which has been a large adjustment for me as well. Eating together as a family has made me appreciate the dinners I have at home with my own family members.

My time in the hospital has been eye-opening as well. I was in the emergency department the first two weeks and from day one I experienced shock in how different healthcare here is compared to America. Providers here are very resourceful. For example, witnessing nurses drawing blood they utilize a rubber glove as a tourniquet versus the usual tourniquet used in the U.S. I found that to be an absorbing moment for me. Patients who come to the ER are sick or commonly, victims of a bad motor scooter accident. Often patients are in critical condition, but the resources are not always available to provide them with care.

The providers here utilize what they have in a multidimensional way, and I think that is something that I will carry with me for the rest of my medical career.

I am grateful for my first week here. I am learning a lot in the hospital and witnessing so much! It has been humbling thus far and excited for the weeks to come.

Welcome

Currently the global health program is hosting 4 global health scholars at Danbury and Norwalk Hospitals. Dr Trinh Ngoc Thanh, a cardiologist from Cho Ray Hospital in Vietnam, Dr Gabriel Polanco, a cardiology fellow from the Heart Institute in Dominican Republic , Shushanik Isahakyan, the Head of the International Cooperation Department at the National Institute of Health in Armenia, and Dr Pham Le Anh Nguyen, a pulmonologist and critical care specialist from Cho Ray Hospital in Vietnam.

We are welcoming them to Nuvance Health.

Shushanik Isahakyan

The Director of Nuvance Health Global Health Program at National Institute of Health in Armenia

Shushanik Isahakyan is the Head of the International Cooperation Department at the National Institute of Health in Armenia.

She will be spending 3 weeks (May 21 to June 9) with the global health team at Danbury Hospital.

On May 22, 2023, Shushanik Isahakyan - the Head of the International Cooperation Department at the National Institute of Health in Armenia arrived in Danbury for an official visit to the Nuvance Health Global Health Program. Shushanik has been instrumental in driving positive change in the healthcare sector through her involvement in local and international projects. During her time here, Shushanik visited Danbury and Norwalk hospitals, Global Health Academy, Sacred Heart University, and met with the leadership team to get acquainted with the structure and key elements of our program.

On June 5-6, Shushanik, along with Dr. Alexander Bazarchyan - Director of National Institute of Health of Armenia, will attend the Second Global Health Conference. These visits are part of our evolving collaboration with the National Institute of Health of Armenia in efforts to establish a new program site.

We welcome Shushanik to the Nuvance Health Global Health Program and look forward to our fruitful collaboration with the National Institute of Health of Armenia!

Gabriel Polanco, MD

Heart Institute in Santo Domingo, Dominican Republic

Dr Gabriel Polanco arrived in Danbury Hospital on May 8th for one month training in the Cardiology department under the supervision of Dr Robert Jarrett.

“I am thrilled to come to Danbury hospital to experience the way you people deal with cardiology patients and see what I can learn and apply back home in DR. And of course tell you about our experiences and ways of doing things in DR, especially when it comes to the Latin American patient.”

Trinh Ngoc Thanh , MD

Cardiologist, Cho Ray Hospital, Vietnam

Dr Trinh Ngoc Thanh is a Cardiologist from Cho Ray hospital, he arrived in Danbury hospital on May 22 for two months of clinical rotation at Cardiology Department under the supervision of Dr Robert Jarrett.

Pham Le Anh Nguyen , MD

ICU Doctor, Cho Ray Hospital, Vietnam

Dr Pham Le Anh Nguyen is an ICU doctor from Cho Ray hospital. Dr Pham was nominated as a Nair Scholar and arrived in Norwalk hospital on April 10th for two months of clinical rotation in Pulmonary and Critical Care Medicine under the supervision of Dr Robyn Scatena.

Global Local

Section Editor: Ritesh Vidhun

Merge & Acquire: The Modern-Day Business of Running a Hospital

Written by Ritesh Vidhun

Hospitals in America have gone through significant changes over the past few decades. The 21st century brought a wave of advanced technology and treatments along with a wave of steadily increasing costs. Many providers across the United States have relied on smaller high-cost populations but as the industry moves toward value-based payments, many institutions are looking to merge with larger groups in order to avoid financial struggles. This leads to larger organizations being able to control a greater share of the market while having more influence over costs. The increased number of hospital mergers and acquisitions has an overall negative impact on healthcare in the U.S. due to lower competition and higher prices.

The Increase in Hospital Mergers and Market Consolidation: Currently, the top 10 health systems in the United States, which include names such as HCA Healthcare, Ascension, and Trinity Health, control around 24% of the market.1 This staggering number has only been growing over the last decade, with increased hospital mergers & acquisitions (M&As) across the nation. There were a total of 92 M&A deals in 2019, slightly higher than the 90 in 2018 and lower than the 117 in 2017.2 In 2020, challenges brought about by the pandemic attributed to a lower number deals at 79.

What Factors Have Led to This Trend? When examining the increased levels of hospital mergers and acquisitions in the U.S., understanding the principle roots of the trend are important in navigating the complexity of the topic. One of the primary reasons for the growth of M&A deals can be attributed to the shift toward value-based payment reform. Many providers, particularly smaller ones, seek to join larger systems in order to reduce the burden of financial risk. Additionally, merging helps smaller hospitals gain access to more advanced technology, increased standardization, further coordination, and better financial support. Utilization has also been generally declining over recent years, especially during the pandemic. With lower levels of health care spending by the American population, many providers face significant challenges in maintaining their revenue and profits. After all, running a hospital in the U.S. requires some level of business strategy and executives are looking for more ways to stay afloat in this challenging economy.

Although publicly, hospital groups state that the main motivations for mergers and acquisitions are to improve quality and access for patients, there are a series of financial gains that must be explored. Especially in smaller urban or suburban communities, when multiple hospitals combine, insurers are less likely to exclude one from the network despite greater prices or lower quality.3 This gives less prominent hospitals an opportunity to increase their utilization and revenue. The growth in these mergers and acquisitions has significant impacts on the health care market and patient experience as well.

What are Some of the Drawbacks? There is one main concern that health economists and experts have alluded to: higher costs and less access. In most industries, when a handful of groups or companies control a significant portion of the market, it typically leads to them being able to better determine prices due to the reduced competition. Many hospital executives believe this is not true for healthcare, including Dr. Kenneth Davis M.D., President and Chief Executive Officer of Mount Sinai Health System in New York City stating, “the fear that mergers curtail competition, leading to higher prices for medical care, reflects an old way of thinking. Thanks to cataclysmic changes in the delivery of health care, hospital mergers now offer the potential for higher quality and more efficiency.4” These arguments are not always applicable, as multiple studies conducted across the nation have found that the increase in market consolidation over the last decade have, in fact, led to somewhat higher costs for patients due to less competitive markets.5 Organizations are able to bring more weight into negotiations with insurance companies, leading to more expensive contracts and consequently higher premiums for members. This is a very nuanced subject, but in general, research shows that M&A deals do not always lead to patient benefits.

But Don’t Larger Groups Lead to Higher Quality? Arguments in favor of increased mergers and acquisitions often cite greater quality of services and access to advanced treatments. This can certainly apply to smaller hospitals in difficult financial situations, however it does not necessarily apply to the wide majority of deals. A study published in the New England Journal of Medicine examined data on M&As from 2007 to 2016 while comparing a variety of quality measures to determine composite scores.6 It concluded that “hospital acquisition by another hospital or hospital system was associated with modestly worse patient experiences and no significant changes in readmission or mortality rates.” In general, M&A transactions do not lead to significant improvements in the quality of health care that patients receive, and in many cases may actually lead to lower quality. In addition to increased costs, these findings emphasize the dangers of this steadily growing trend.

The Impact of COVID-19 & Looking Ahead: Prior to 2020, the number of hospital mergers was on an increasing trajectory. However, the COVID-19 pandemic has had a variety of implications that led to fewer M&A deals last year, from decreased utilization of services to massive drops in health care revenue.7 These factors have decreased incentives while increasing risks for health groups to pursue merger and acquisition deals.

Although there was stunted growth on market consolidation during the pandemic, the trend continued afterward. This is apparent right here in Connecticut with the expansion of Yale New Haven Health into greater Waterbury. The number of independently owned hospitals has gone from 23 in 2000 to 6 this year.8 Although the effects are still unclear, there is a cause for concern especially in rural communities (as discussed in previous editions). If we seek to minimize these challenges and increase access to high quality services in this country, a series of important questions must be answered: Can the government restrict M&As in order to promote competition in the healthcare market? Should there be a limit to the size that hospital groups are able to grow? If public health insurance grows in the U.S. what effects will this have, if any, on the current trend of M&As?

This trend will continue to have serious implications over the coming years, and is something that needs to be addressed if we seek to make healthcare more equitable and accessible for all.

References:

https://www2.deloitte.com/us/en/insights/industry/health-care/hospital-mergers- acquisition-trends.html

https://www.kaufmanhall.com/insights/research-report/2020-mergers-acquisitions- review-covid-19-catalyst-transformation

https://californiahealthline.org/news/sutter-health-class-action-lawsuit-hospital- consolidation-medical-prices-health-care-costs/

https://www.wsj.com/articles/kenneth-l-davis-hospital-mergers-can-lower-costs-and- improve-medical-care-1410823048

https://academic.oup.com/qje/article/134/1/51/5090426?login=true

https://www.nejm.org/doi/full/10.1056/NEJMsa1901383#article_citing_articles

https://www.healthsystemtracker.org/chart-collection/how-have-healthcare-utilization- and-spending-changed-so-far-during-the-coronavirus-pandemic/#item-covidcostsuse_ marchupdate_1

https://www.ctmirror.org/2022/05/08/as-hospital-systems-grow-consolidate-rural-patients- ct-lose-services-labor-delivery-intensive-care/

Contact: ritesh.vidhun@tufts.edu

Hispanic/Latinx Voices; Stories from our Community

Section Editor: Elvis Novas

Written by Elvis Novas

Advisor for the Dominican Community Center and member of the Board of Directors of Housatonic Habitat for Humanity, Danbury, CT

“I am very grateful for the privilege of being selected as editor for the column “Hispanic/Latinx Voices: Stories from our Community ‘’ of the Global Health eMagazine.”

My desire for a better community has been the guide to introduce me to community work, specifically in the Hispanic/Latinx community. This experience has allowed me to see and treat people in our community with great human and professional values; men and women who just need a platform to share their stories and amplify the voices of others.

Our vision for the column “Hispanic/Latinx Voices: Stories From Our Community” is based on the interest of making our people, culture, values, and points of view known and at the same time motivate our audience to be more interested in our community.

With this, we seek greater visibility for our community, the opportunity for our people to expose their talents and abilities to communicate and for others to know our true stories. I encourage you to follow us each month as we feature inspiring stories from our Hispanic/Latinx community in the city of Danbury, Connecticut. Please feel free to send me your ideas or thoughts at enovas@gmail.com.

On this occasion we are pleased to have a great article from Denisse Rodas, a 21-year-old nursing student who graduated in May 2023 from Western Connecticut State University with her Bachelor of Science. She will start her nursing career in the Med-Surg floor unit and Danbury Hospital. She was also part of the Latinx Panel last year.

Denisse Rodas is a 21-year-old nursing student who graduated in May 2023 from Western Connecticut State University with her Bachelor of Science. She was born and raised in Ecuador, and at the age of 13 years old, she migrated to the land of opportunities. She started her path to achieving the American Dream as an undocumented student and encountered various challenges, as many scholarships, financial aid, and jobs were not available due to her immigration status. After eight years of commitment to learning a new language and adapting to a new country, those barriers have not stopped her from pursuing her dream of becoming a successful nurse. During her journey in nursing school, she participated in various extracurricular activities, including her role as a secretary in the Student Nurses Association, a peer nursing tutor, and a Blood Drive Ambassador with the Red Cross. She is a Kathwari Honors Program Scholar, a Henry Barnard Award recipient, and was inducted into the Sigma Theta Tau International Honors Society of Nursing, Kappa Alpha Chapter.

Due to the barriers, she has valued the importance of participating in leadership opportunities to advocate for the undocumented community. Being an undocumented student brought her closer to Connecticut Students for a Dream, a youth-led organization that fights for the rights of undocumented families and students. As an active member for more than five years, her community service work has focused on doing school presentations and leading membership meetings and events that have benefited the Latino and Hispanic communities by raising awareness about issues affecting the immigrant community. She became the College Access Program Fellow and supported undocumented students’ transition from high school to college. She tutored senior high school students and helped them understand the basics of college and apply for college, scholarships, and financial aid. She was part of the “Afford to Dream Campaign,” which allowed undocumented students across CT to be eligible for the AACTUS, which is the application designed specifically for undocumented students to apply for financial aid.

As a nursing major, serving the community has given her purpose, and even though she is no longer an undocumented student, she continues to advocate for undocumented families and students desiring to achieve higher education. Currently, she is preparing to take the NCLEX and is enthusiastic to begin her nursing career in the Med-Surg floor unit and Danbury Hospital. She desires to advance her career by applying to graduate school to become a nurse practitioner and move forward to work towards an EdD in nursing education. As a future nurse, she hopes to be compassionate and empathetic and is dedicated to treating everyone with respect and providing high-quality care. She desires to make a difference regarding gender, social class, immigration status, and ethnic background. Lastly, being a first-generation Latina student has allowed her to honor her roots and celebrate her Ecuadorian culture and inspired her to support undocumented students and families across CT.

The Voice of Ugandan Students

Section Editor: Joshua Matusuko

COLONISATION AND DECOLONISATION OF GLOBAL HEALTH CURRICULUM AMONG MEDICAL SCHOOLS IN UGANDA

Written by Joshua Matusuko

Medical student at MaKCHS

Colonization continues to have a long-term significant impact on health systems, global health education, and healthcare practices in many countries that were colonies not long ago, including Uganda. Of the many influences that colonialism continues to have in healthcare, a colonial mindset among medical students and health workers in low and middle-income countries (LMICs) stands out to be the most significant to date. This issue makes it challenging to find long- and short-term solutions to the continued home health problems and inequalities that still plague many communities, despite possessing richness in numerous other resources. New physicians are often ill-equipped to address the true causes of health disparities, which are deeply rooted in historical, social, and political contexts. The current global health education curriculum in Ugandan medical schools fails to adequately discuss issues related to colonization and decolonization, which are crucial for understanding these health disparities. As a result, medical students in Uganda lack the knowledge and skills necessary to critically analyze the impact of colonialism on healthcare, to recognize its ongoing effects, and to work towards decolonizing medical practices. Additionally, they lack the skills to effectively navigate the complexities of global health, perpetuating the inequities in the healthcare system stemming from the gap in their medical curriculum.

While numerous efforts have been made to decolonize global health education and improve health outcomes, there remains a colonial mentality among most of medical students in Uganda and in other LMICs—so even if advocates push for structural changes and power balances, by not tackling the core issue, which is mentality and mindset, we risk wasting most of our efforts. There is still a significant knowledge gap in global health curricula regarding colonization and decolonization in Ugandan medical schools, making it necessary to introduce this education at MakCHS and other institutions. Closing the knowledge gap will help fight the colonial mindset and ensure that more healthcare professionals are empowered to address the long-standing legacies of colonialism, improving the health of all.

Global Mental Health

Co-Editors: Krista Buckley, MD and Elina Mukhametshina, MD

Global mental health is a growing field of Global Health that seeks to address the burden of mental illness. Mental illness affects people of all ages, genders, and cultures and is a significant contributor to the global burden of disease. When it comes to mental health, all countries can be thought of as developing countries. Vast inequities exist in the distribution of and access to mental health resources, not only between but also within countries.

Global mental health aims to promote the prevention, treatment, and management of mental illness worldwide while also addressing the social and cultural factors that contribute to mental health disparities.

The Global Mental Health column endeavors to shed light on the inequalities surrounding mental health and shares inspiring narratives of mental health advocates from around the globe.

Svanjita Berry, RUSM, MS4

Global Health Elective alumni (February 2023)

Following are two short stories inspired by my global health experience in India. I was fascinated by the role that religion played in both instances. It made me reflect on how each one of us formulate our own realities based on where we are born, what we see, what we learn, and what we feel throughout the course of our lives. Our personalities and behaviors are simply a manifestation of those individual realities interplaying with our neurobiology.

“Lakshmi”- The Hindu goddess of abundance

Golden threads weaved into her bright red saree. The saree is draping over her torso and wrapping over her head covering most of her face, though one could still see the bright red ‘bindi’ (dot on the forehead) underneath. Her hands adorned with glass bangles embellished with tiny rhinestones. Her palms and feet were painted with ‘alta’ (red dye). As she walked into the room, her anklets made the most beautiful clinking sounds. Heads turned in awe as she made her way through, till she saw an empty bed and very gracefully sat down with one leg crossed and the other leg hanging down. Her hands quickly transitioned into ‘mudras’ (hand gestures) while she moved her gaze across the room. “I am Lakshmi” she said. “Tell me more,” replied the psychiatry intern, while the other patients continued to stare.

The mortal who married a god

“Lakshmi and Saraswathi (Hindu Goddess of Wisdom) are trying to ruin my life” said the patient pointing at her sister and her nurse. “They are jealous of my marriage with Shiva (Hindu god of destruction and transformation). “In 1996, I heard Shiva singing Tu Hi Re.. (a popular love song in the 90s). Since then, we have been lovers. He would come to me in different ways, sometimes through my brother’s friend Yogesh (another name for Shiva). I have never seen him, but I can hear his voice and feel him. I have attained supreme pleasure during intercourse with him. I can feel his ling (penis) penetrating and rubbing against my yoni (vagina). We have 2 kids together - Ganesh and Mayur (actual names of Shiva and Gauri’s sons in Hindu mythology). He guides me on how to live my life. He protects me from my neighbors and my sister who are trying to poison me. All the other gods have tried to kill me before. Vishnu (Hindu god of preservation) shot poisoned arrows at me and sent his snakes to fill me with their venom. I could feel the snakes crawl on my skin and the arrows hurt so bad that I couldn’t move for days. They also tried to slit my throat and I lost my voice for months. But my Shiva saved me and gave me back my voice. I am Gauri, his wife, and through him I have the power to destroy the world if I want to.”

How many delusions are too many delusions? I asked myself after this 2-hour-long detailed patient interview in central rural India. My back had started to hurt from sitting on a tiny metal stool placed next to the patient bed, but the behavioral health enthusiast in me had refused to leave. My single sheet of paper was overflowing with my notes and observations. Her medical charts revealed that in the last 27 years, her positive symptoms had never responded to any psychiatric medications, despite adequate trials with Clozapine and ECT. How could a case be this complex? How could the patient’s developmental and social history shape her psychiatric illness to this extent? Were the delusions the basis of her hallucinations or did the hallucinations fuel the delusions? Had her long-standing delusions become fixed memories? I had an endless list of questions that needed to be addressed. I knew this case was going to be the highlight of my clinical experience in India.

Art To Remind Us of Who We Can Be

Co-Editors: Mitra Sadigh and Elina Mukhametshina, MD

During times of confusion, tribulation, grief, uncertainty, and despair, the arts enliven us by reintegrating the disjointed pieces of ourselves and replenishing them with clarity and hope. The arts remind us of our individual and collective potential to grow, evolve, and transform. They remind us of what and who we can be and what we can create. In this new section, we bring you works of art that have moved and inspired us. We encourage you to also share works that have inspired you.

This month we are highlighting one of the Latinx artists from Danbury.

Jacqueline Cabrera

Jacqueline is a Dominican-American, abstract artist who has always been fascinated by the beauty of nature and people. She studied sociology at Baruch College in New York City, but as she pursued her degree, she realized that there was more to life than just theory. She had always been artistically inclined, but she felt like she couldn’t create the same kind of work as others.

In 2018 she moved to Danbury where she was able to reconnect to nature just as she did when she was a child growing up in a Campo in the Dominican Republic. Reconnecting to nature allowed her to connect more to herself and understand herself in a more profound way. It was while walking through the East branch reservoir in Brewster that she realized, after years spent away from art, how important it is to express herself in her preferred styles. Jackie incorporates natural elements such as rocks, feathers, sand and soil into her paintings.

Nowadays, she creates canvas pieces that are both beautiful and thought-provoking. Jackie believes in the power of art to make the world a better place. Jackie’s goal is to inspire others to find beauty in their own unique way of seeing the world—and we can’t wait to see what she comes up with next!

Jacqueline Saldana

Ms. Saldana is a Dominican born artist whose work has been featured in galleries in both New York City and New Hampshire. She started painting at the age of 5 when she was in bed recovering from Polio and has never stopped since. Jacqueline moved to the United States in 1996. Her mother and sister had migrated years earlier allowing her to acquire a US visa as soon as her mother became an American citizen.

She is the mother of four children who now have grown up and are living their own lives here in the United States. She says that one of her greatest joys has been to help her children come to this country, where they can find opportunity and happiness. She is now grandmother to 5 adorable little children who adore her.

When asked what inspires her, she says it’s her family, nature and its beauty. Her paintings are always inspired by these things and reflect a love for life itself through her lens. She incorporates many landscapes, shades and colors to always give her paintings a sense of the Dominican Republic, preferably some kind of body of water.

Section Editor: Dilyara F. Nurkhametova, MD, PhD

Director of Nuvance Health Global Health Electives Program for AUC/RUSM

This new column exhibits the beauties of our planet earth and our everyday destructive actions against it. We are witnessing Earth undergoing a profound transformation. In this recently launched section, we appreciate the gems of our planet while raising awareness of climate change. We invite our global health community to share photos, videos, inspirational resources, and stories. We want to hear from you how climate change affects people and health in your part of the world.

Preserving forests means culture change

EDITORIAL| VOLUME 7, ISSUE 5, E346, MAY 2023; The Lancet Planetary Health; DOI:https://doi.org/10.1016/S2542-5196(23)00085-2

In this Editorial authors discuss the existing challenges for forest preservation, highlight the role of planetary health researches “in understanding, quantifying, and communicating the value of intact, biodiverse forest for human health and wellbeing”. The authors highlight the need for “a wider cultural shift toward recognizing the full value of intact forests and other natural ecosystems; this will be hard won, but is vital if we are to stop undermining our own wellbeing.”

Read the full text here

Upcoming events and Webinars

June 6, 2023, 8:30 AM – 5:00 PM (virtual or in-person)

5th Annual Clinical Climate Change CME Conference: Clinical Care for Workers in the Climate Crisis

Register via this link

June 13-15, 2023 (virtual)

Global Community Health Annual Workshop

The third edition of the Global Community Health Annual Workshop will take place from 13 till 15 June 2023. The overall workshop theme is “Sustainable community health: practice-based solutions for today’s challenges”. The theme will be explored via three sub-themes, one for each workshop day: Food security, Mental health, and Environmental health. Organizers are the UNESCO Chair Global Health & Education, University of Clermont Auvergne, University of Huddersfield, International Union for Health Promotion and Education (IUHPE)and EHESP School of Public Health.

Read more about the event here, register here

BigPicture Natural World Photography Competition: Website | Facebook | Instagram

Innovation and Technology in Global Health

Section Editor: Swapnil Parve, MD

Written by Swapnil Parve, MD

Director of International Affairs at the NH/ UVMLCOM Global Health Program

Sal Khan believes that artificial intelligence (AI) has the potential to transform education for the better. “We’re at the cusp of using AI for probably the biggest positive transformation that education has ever seen,” he said in his 2023 TED talk.

Sal Khan’s 2023 TED Talk: AI in the classroom can transform education

Nursing Division

A Note from the Editor: Catherine G Winkler, PhD, MPH, APRN-BC

Director of the Nuvance Health Global Health Program Nursing Division

Strengthening Healthcare Systems

Strong healthcare systems are needed for all people to achieve timely access to quality healthcare to promote, restore and maintain health. Improving healthcare systems In the USA as well as on a global level requires administrators and healthcare leaders to take a hard look at the delivery of care, the cost of care, the timeliness of care and “the caring” in healthcare.

After the pandemic, change has been necessary on behalf of all healthcare providers in the delivery of care, the content of care and the timeliness of that care. Front line providers needed to don extra gear, change protocols, use resources differently and reprioritize their work with staff levels low and with care complicated by isolation and uncertainty.

Patients and their families also needed to make ongoing changes since the pandemic by making careful decisions about whether they should seek care, when to seek care, how to seek care, and from what source in what venue would accessing this care be possible.

Healthcare systems and administrators have changed too – but it requires more effort because they need to recognize problems and develop strategies, quick responses, and activities to allow providers to do their work effectively, and to sustain positive changes now through the next pandemic or crisis. Healthcare organizations and their leaders need to meet the needs of their staff and the patients that they provide healthcare to every day.

Delivery of care needs to be available and timely. Often with large healthcare systems that span across a state or states that have set themselves up with service lines designed to manage expensive disease states such as orthopedics or cardiovascular care - lose sight of what services their communities need that may be lost leaders financially but are vital to the local people such as pediatric services or primary care. A shift should happen to review the community needs and then formulate a plan about how to access it. Does it make sense to have telemedicine visits, clinic, or home visits? Then once decided, look beyond the hired call service that may pick up the call in 30 seconds but still struggles to get a patient seen within a month. Community connectivity is needed to ensure that in addition to service lines, rapid response, urgent care, emergency care, and primary care are offered and accessible locally. Where is the care in healthcare?

Care needs to be cost-effective but should also be safe and convenient for the patient that needs an outpatient procedure. Perhaps a cholecystectomy can be done same day, but in thinking about the secondary consequences of that surgery and the issues with urinary retention or symptom management – does it seem like a good idea to have the 75 year old patient need to follow up on Friday evening after the procedure in the ED as their only course of action available to have a urinary catheter placed or ongoing nausea treated? This happens often, and patients bear the burden of an ED visit with the associated health risk and cost. Where is the care in healthcare?

Patients who are 10 minutes before going into surgery should not have to find their credit card in their clothes that have already been placed in the pre-op locker to pay an out-of-pocket expense to the hospital before they are wheeled into the OR. Perhaps this could have been considered the week before so that the frightened patient is not further troubled. After that the same restructuring of finances would make sense without asking the parents of a sick child going in at 5 in the morning for an invasive procedure to also pay for the estimated cost of care. Where is the care in healthcare?

Communication and transparency need to be either reinstated or developed post pandemic. With the primary care physician replaced in the hospital setting by hospitalist and intensivist along with snfist - then without timely communication and perfect electronic medical records that are secure and available-important information is lost, gaps in care occur and patients and the families suffer the consequences. A phone call or an in-person visit is best and should be done in addition to information provided in a patient portal. Some patients have 5-10 portals they need to manage and still data is missing or lost. Access to care and coordination of that care needs to be done across platforms and locations. Where is the care in healthcare?

Environment of care needs to be upgraded with more privacy, that’s accessible space to meet the needs of a child, a person who uses a wheelchair, or a person with blindness or a hearing deficit and with resources and clean areas available to promote a patient’s independence, confidence, safety, and health while enabling front line healthcare providers to do their work.

Healthcare administrators need to support the advancement of science with time for providers to conduct research, review literature and consult with colleagues. The interconnectedness of the world requires administrators and leaders to strengthen partnerships with colleagues across the world, as well as down the street and around the corner to improve public policy, encourage advocacy, and work on screening, health promotion and disease prevention. There are major changes in patterns and trajectories of health, disease, and aging and to improve and sustain change, healthcare leaders must adapt now to the changing world to ensure that the care is reinstated in healthcare and that it is sustainable.

Comments

Written by Mary Kincart, MS, RN

Dr. Winkler has provided a candid and comprehensive look at the challenges in healthcare we face as a nation and worldwide. The work to restore healthcare systems has been greatly impacted socially, emotionally, physically, and financially by the Covid pandemic. In many ways healthcare has experienced great setbacks and in other ways we have learned to be nimbler, more resilient, and more innovative.

Treatment of chronic illnesses and preventative health measures were suspended during the acute phase of the pandemic, leading to a backlog of unaddressed healthcare needs by many. In addition, the nation is experiencing a significant influx of migrants from other countries, placing an even greater strain on an already vulnerable system, and greatly impacting access to care.

The loss of healthcare providers and staff, from illness and/or burnout, as well as the massive financial impacts on hospitals, practices and healthcare facilities, compel healthcare leaders to address these challenges in new and innovative ways. The past several years have forced us to think differently about how we deliver healthcare. Specialists such as Intensivists and Critical Care Nurses provided virtual guidance to ICUs to support care to a greater number of patients. Virtual visits became the “norm” for addressing the needs of patients with chronic illnesses as well as those that needed non acute medical attention. Pop-up mobile testing and vaccine stations were implemented. These are only a few examples of the capabilities of healthcare leaders that will prove to be invaluable as we work towards strengthening our Healthcare Systems in the future.

In a recent publication by Forbes contributor Bernard Marr, Dec 6, 2022, Mr. Marr provides an overview of trends that are addressing some of the challenges described in Dr. Winkler’s article. Mr. Marr describes the many uses of artificial intelligence in healthcare delivery. He gives examples such as remote surgery, virtual hospital wards, virtual homecare and the building of online communities linked to specific health conditions that can provide information, education, and support. The public has already integrated the use of wearable medical devices to monitor health and track sleep patterns, activity, vitals signs, blood pressure, and EKGs to aid in the management of chronic medical conditions.

Financial recovery also requires resiliency and innovation. Administrators and Leaders must support the optimization of private and Medicare/Medicaid value-based care models without further burdening the frontline providers and staff. Embracing the opportunities made available through technology and artificial intelligence affords our healthcare systems the ability to move forward and gain advances in healthcare.

Women’s Health Education

Section Editor: Sarah Cordisco, RN

Staff Nurse at the University of Vermont

Cesarean Sections

Written by Sarah Cordisco, RN

Across the globe, the maternal mortality rate is decreasing, yet remains extremely high. In 2020, about 287,000 women died during and after pregnancy and childbirth (WHO), most of which could have been prevented. An analysis published in The Lancet, found that maternal deaths in LMIC are 100x higher than those in high income countries, and a 1/3rd of all babies in some regions do not survive cesarean section. The use of cesarean sections has continued to rise globally and now they account for more than 1 in 5 childbirths (or 21% of all births). By 2030, this number is expected to reach nearly a third or 29% of all births (WHO, 2021). In LMIC countries, about 8% of women give birth via cesarean section, which indicates a lack of access to this type of surgery compared to MHIC countries where rates are as high as 43% of all births. Maternal death rates may be high in LMIC where the cesarean section rate is low due to lack of access to resources and care, and lack of surgical intervention in a timely manner.

Cesarean sections are often lifesaving procedures when vaginal delivery would pose great risks, but it is important that health care systems are doing these operations appropriately and safely with the proper post-op care; as well as, having the proper indications for this procedure. Cesarean sections are typically indicated during labor dystocia, abnormal or intermediate fetal heart rate tracing, fetal malpresentation, multiple gestation or suspected fetal macrosomia (Safe Prevention of the Primary Cesarean Delivery, 2014.). Some women may also choose to have a cesarean section due to their own medical history (such as thrombocytopenia), having previous traumatic births, or in cases where a vaginal birth is unwanted.

While this procedure may be elective or emergent, it is important for women to understand the risks and benefits, as well as, the outcomes, specifically in the realm of maternal and natal deaths. In LMIC the risk of death while undergoing a cesarean section was 7.6 per 1000 procedures, the highest burden being in Sub-Saharan Africa. The overall rate of stillbirths in babies born via C-section was about 56 per 1000, with the highest rates in sub-Saharan African (82.5/1000). The risk of infant death (stillbirths

or deaths within the first week of life) is about 84 per 1000 C-sections, with the highest rates in the Middle East and North Africa (Study, 2019). Women undergoing emergency C-sections are also twice as likely to die compared to those who had elected to have a C-section, and this risk increased 12x when the surgery was performed during the second stage of labor. Similarly, the risk of neonatal deaths increased 5x with emergency C-sections compared to elective and 10x when the procedure happened during the second stage of labor, compared to the first. About a third of all maternal deaths associated with a cesarean section occur due to postpartum hemorrhage (32%), pre-eclampsia (19%), sepsis (22%) and anesthesia-related causes (14%) (Study, 2019).

Through the research on the outcomes of this procedure, the gaps in resources, skill and knowledge about C-sections are seen and highlight the need for more training and education. There is a high need for interventions and implementation strategies to be put in place to ensure that this life saving procedure is done correctly and has the appropriate health outcomes.

References

Caesarean section rates continue to rise, amid growing inequalities in access. (n.d.). Retrieved April 24, 2023, from https://www.who.int/news/item/16-06-2021-caesarean-section-rates-continue-to-rise-amid-growing-inequalities-in-access

Maternal mortality. (n.d.). Retrieved April 24, 2023, from https://www.who.int/news room/fact-sheets/detail/maternal-mortality

Study: Maternal deaths from cesarean sections far higher in low and middle-income countries. (2019, March 29). News-Medical.Net. https://www.newsmedical.net/news/20190329/Study-Maternal-deaths-from-cesarean-sections-farhigher-in-low-and-middle-income-countries.aspx

Study: Maternal deaths from cesarean sections far higher in low and middle-income countries. (2019, March 29). News-Medical.Net. https://www.news-medical.net/news/20190329/Study-Maternal-deaths-from-cesarean-sections-far-higher-in-low-and-middle-income-countries.aspx

Safe Prevention of the Primary Cesarean Delivery. (2014). Retrieved April 24, 2023, from https://www.acog.org/en/clinical/clinical-guidance/obstetric-careconsensus/articles/2014/03/safe-prevention-of-the-primary-cesarean-delivery

Among the Letters

Hello everyone,

We are writing to express our sincerest gratitude for your generous donation to our recent fundraiser for the small school in Uganda with a big name “Legacy”. Thanks to your kindness and generosity, we were able to raise a total of $4250, which allowed us to purchase the following:

1. Playground including swing set, spinner and multifunctional unit along with soccer balls

2. Desks

3. Backpack for each kid which included a pencil storage unit, stack of 10 notebooks, 10 pencils, a crayon set, a coloring pencil set, sharpness, erasers, and colored pens.

4. Crocs for each kid

5. Candy goodie bags

6. Textbooks for teachers per grade level

7. White chalk and colored chalk for each classroom along with erasers

8. Mini library encompassing atlas, dictionary and fun reading books.

Your contribution has made a significant difference in the lives of these children and their community. They now have access to the basic necessities that they need to succeed in school, which will help them build a brighter future. We are incredibly grateful for your support in making this possible. We are excited to let you know that we have recently released a video that showcases the impact of your donation. The video shows the children at “Legacy” using the school supplies and playing on the new playground. It is truly heartwarming to see the joy and gratitude on their faces. You can view the video on our YouTube channel at https://youtu.be/rcwqMy83_w0. We hope that you will take the time to watch it and see the impact that your donation has made. Once again, thank you so much for your support. We could not have done this without your generosity and kindness.

Sincerely, Asima, Alla and Arezou,

PGY-3 residents at Connecticut Institute For Communities

Announcements

The Second Global Health Conference

Welcome

Dear colleagues and friends of the Global Health Program,

It is with great pleasure that we invite you to the Second Annual Nuvance Health/UVMLCOM Global Health Conference, which will be held from June 4th through June 6th, 2023. We hope to create a thoughtful educational platform for the exchange of information and ideas, with networking and reflection, on our decade long journey together. Our hope is to build stronger partnerships and friendships with the goal of improving patient care through enhancement of medical education.

On behalf of the Global Health Team,

The Directors of the Second Global Health Conference

Majid Sadigh, MD,

Director of Global Health Nuvance Health/ UVMLCOM, Christian J. Trefz Family, Endowed Chair in Global Health at Nuvance Health

Mariah McNamara, MD

Associate Director of Global Health Nuvance Health/ UVMLCOM

Link to the program and registration

Home | The Second Global He (globalhealthday2023.com)

Article of the Month

Addressing the issue of a depleting health workforce in subSaharan Africa

Lancet, May 20, 2023

Naomi Chinyere Chikezie, Deborah Oluwaseun Shomuyiwa, Ebere Angela Okoli, Ifebuche Maureen Onah, Oluwaseun Omolade Adekoya, *Greatman Adiela Owhor, Adeniyi Ayinde Abdulwahab

Health-care workers have a crucial role in improving health outcomes, and their migration has harmed the quality of health services in sub-Saharan Africa. The region has 25% of global diseases,1 and only 3% of health workers globally, highlighting a severe shortage of skilled professionals to tackle high rates of mortality. The main reasons for migration are poor working conditions, low remuneration, and a scarcity of career development opportunities. Insecurity and high crime rates also contribute to migration in countries such as South Africa.1, 2

A study done in South Africa showed that the main reasons health professionals migrated were corruption, personal and family safety, poor infrastructure, and their children’s future.3 To address this issue, the retention of health-care workers should be prioritised in the national planning process. Incentive packages, better work environments, team training, and opportunities for career advancement can improve job satisfaction and develop positive work attitudes.

Harnessing technology can also benefit health-care systems by facilitating patient education, providing seamless access to medical records, and reducing the workload of health-care professionals.4 Improving community health workers’ programmes will help to enhance service delivery.5 Creating a balance of duties so that professionals’ activities match their qualifications can improve working conditions in health systems.

A global survey from the Organisation for Economic Co-operation and Development found that 79% of nurses and 76% of doctors were carrying out processes for which they were overqualified.6 Restructuring service delivery processes to minimise tasks and optimise disease management and service delivery is integral to addressing this issue. The mobilisation of preventive health-care approaches in health systems can also work in the long term to reduce the workload of health-care professionals, reduce emergency rates, and prevent complications.

Overall, the depletion of the health workforce in sub-Saharan Africa is a crucial issue. Retention of health-care workers depends on the creation of supportive environments that enhance service delivery, work culture, and systems to improve population health outcomes. Improving the health delivery landscape in sub-Saharan Africa is essential to retain the health workforce and reduce migration. Policy development is required to promote retention, provide technology to optimise service delivery, improve work packages, and revamp health care; ultimately, enhancing preventive care can stall the depletion of the health workforce and improve the quality of care.

Addressing the issue of depleting health workforce in Sub Saharan Africa

Video of the Month

International Nurse Executive Committee (INEC)

The international nurse executive committee (INEC) met in May 2022. It is our third meeting, and is comprised of members from the United States and Uganda. Many committee members are in administrative and faculty positions and include student and experienced nurses We went to visit a primary school with very limited We We went to visit a primary school with very limited resources in a small rural community. It was a humbling experience to be with children who were so happy and joyful despite not having the bare minimum needs in a school. After seeing that school and the hardships those children are going through to obtain an education, Alla, Arezou and I decided to raise funds to help the school out.

Link to the video:

To watch the video, please visit https://www.youtube.com/watch?v=ZE6j3agnkZE.

Another example of the beauty and blessings the GH program brings to the world, fueled by caring and generous hearts.

SK

This is such a beautiful and powerful story.

It is so moving to see the joy in those who are receiving the gift but also in the young narrator/benefactor who said “this is the happiest day of my life”.

God bless all of them for their love of fellow man.

JM

Such a beautiful video capturing the pure joy and happiness of children and even adults, upon their receiving such a gift. Glorious smiles that warm the heart. Thank you for sharing.

PA

Congratulations

Written by Stephen Scholand, MD

Congratulations to our dear Dr. Khoa, on his graduation with a Masters in Health Professions Education from Boston University.

We proudly celebrated the graduation of Dr. Khoa, our esteemed Nuvance Global Health scholar and now faculty, on May 18, 2023. It was a perfect day – and absolutely wonderful to share in his successes along with other graduates from Boston University. The occasion filled us with pride and anticipation for the future of healthcare in Vietnam.

Dr. Khoa trained at Vietnam’s prestigious University of Medicine and Pharmacy at Ho Chi Minh City. He has consistently amazed us with his exceptional dedication and pursuit of excellence. He has a genuine passion for health education that is exemplified by his active involvement in our Nuvance Global Health program. He ultimately envisions promoting educational reforms and advancements in Vietnam, particularly for vulnerable populations.

Dr. Khoa’s successful completion of his Masters in Health Professions Education showcases his remarkable intellect and unwavering commitment to advancing medical education. We eagerly anticipate the transformative changes and invaluable contributions he will continue to make in the field of Global Health.

Congratulations Dr. Khoa!

To Julia Nyamururu, BSc

The new coordinator of the global health program at University of Zimbabwe faculty of Medicine and Health Sciences

Julia Nyamururu works at the University of Zimbabwe under the Faculty of Medicine and Health Sciences in the Electives Office as Office Manager since 2008 up to date. She is a holder of a BSc Psychology from Women’s University in Africa. She is a passionate young lady, self-motivated and a goal getter.

Photo News

ECC Soccer 2023

Graduation of Dr. Khoa

Global Health Scholars