A Brief Introduction: HIV Research in Swaziland

by Loxley Denzil Christopher Bennett II, Columbia College Senior majoring in neuroscience & behavior

Next Generation Fellows

Me in the first row, bottom left, and the other Next Generation Fellows (photo credit: ICAP)

For the past few weeks, I have been working with the International Center for AIDS Care and Treatment Program known as ICAP.  Although the organization is only 10 years old, it has played an instrumental role in global health, particularly in scaling up HIV prevention and care by working with institutions in sub-Saharan Africa and Central Asia.  Even as a senior at Columbia, I’m still impressed when I discover a new way that Columbia University is making the world a better place through advancements in everything from medicine and public health to social justice.

However, three years at Columbia have taught me to maintain a critical eye in all matters, especially the ones that seem benevolent; and this skill served me well as I searched for ways to spend this summer. ICAP was one of very few programs I found that allows students to participate in a project that 1) provides a sustainable and significant impact on the global community and 2) is conducted in conjunction with local physicians and researchers as a collaborative effort. With its international teams of experts and funding from PEPFAR (the United States President’s Emergency Plan for AIDS Relief), ICAP has already brought us so much closer towards an AIDS-free generation. Even though I’m just a lowly research fellow, the ICAP team in Swaziland will use my work to continue improving approaches to HIV treatment and I have the fantastic opportunity of immersing myself in Swazi medicine, society, and culture by working with their medical pioneers.

The collaboration and partnership between the U.S. and Swazi experts who designed and conducted this study also allows me to serve the global community as an American without feeling like an imperialist…which is nice.  The common narrative surrounding Americans swooping in to “fix” or “save” foreign worlds in fifteen minutes abroad and humanitarian and medical tourism in general are lethal to both the ethereal world of bioethics and to the real world where quick, interventions from the outside are substituted for sustainable change.

Loxley and Zebra

Me in Nisela at a safari with a zebra that was absolutely obsessed with me!

While in Swaziland, I’m trading True Blood for hunting in Maloma. I’m trading lazy days on the beach for bumpy rides on safaris.  And most importantly, I’m trading a summer working and studying in the U.S. healthcare system for a transformative fellowship researching HIV and antiretroviral therapy (ART) in Swaziland.  In a nutshell, I collect patient information from the 20 hospitals and health centers participating in ICAP’s Link4Health study in Swaziland and use that data to gauge the risk of initiating ART.

In upcoming posts, you should expect to see a lot more about yours truly, my work with ICAP in Swaziland, and some musings on medicine, bioethics, and the intersection between science and social justice.

Salani kahle (Stay well).

Fostering Health Literacy: Simple Messages Simply Work

Hannah Sabbagh, MPH ’14 in the Department of Sociomedical Sciences

HannahSabbaghPhoto

We’ve all been confused after reading a health-related article. No matter how important the tip or advice, sometimes health information can seem so complex that we do not process it in a way that sticks. The more overwhelming the message, the more likely we’re going to ignore it and leave our old habits unchanged. As a Health Promotion student in the Department of Sociomedical Sciences in the Mailman School of Public Health, I’ve learned that this response is common. But this is not what practitioners hope to elicit. Through my internship with the Harlem Health Promotion Center, I practice crafting health messages that will be processed and remembered, rather than leave the audience confused and flustered.

When I began my internship, my first few days were spent reading a large stack of papers about health literacy that my supervisor Carly Hutchinson, director of Communications and Community Relations, handed to me, familiarizing myself with the topic. What I discovered in those pages, and what I have been discovering on the job, is that the importance of easily understood and audience-appropriate health messages cannot be overstated. I have learned that while it may seem easy to make health information simple, fostering health literacy is more complex than you might think. It can take several weeks of refining before a health message is ready to be shared with the larger community.

My supervisor, Carly Hutchinson, handing me health literacy documents.

My supervisor, Carly Hutchinson, handing me health literacy documents.

Often, a message of health is lost in translation. Making health literacy a regular consideration can prevent this from happening. To produce health literate content, the Center relies on a dictionary of words used throughout the website that we call our “Healthopedia.” It is a consistent part of our content creation and it helps our site users with terms that they may be unfamiliar with. The words range from “biopsy” and “gastroenterologist” to “smoothie” and “organic.” We link terms to the Healthopedia as often as possible, and we add anything we think might be unclear so that readers not only understand the intended meaning of what we’re saying, but also learn new things.

Providing definitions and avoiding flowery language is just one method we use to keep our site easily accessible. I recently wrote a definition of Mood Disorders, but boiled it down to a quick sentence: “A mood disorder is a psychological condition that results in changes in mood, such as depression.” Within the definition itself, a site user would then have the opportunity to look at the definition of depression if he or she wanted more information.

Just an average day working onhealth literacy.

Just an average day working on health literacy.

In writing Healthy Tips, we make sure that we do our best to understand the needs of our website users and encourage realistic goals. We try to promote small changes that make a big difference and seem easy to accomplish. For instance, we might encourage our readers to take walks during a lunch break if they don’t feel they can spare 30 extra minutes per day to exercise.

Another part of making our content as accessible as possible is making sure that people are motivated to read it. Our Healthy Tips of the Week are usually no more than 200 words, and we use bullet points and numbered lists to highlight important action steps or bits of information. This makes it easier for our readers to sign on and find the meat of what we want to tell them right away. There are no large, dense blocks of text, and the site utilizes a lot of colorful pictures.

We often get together to discuss the best ways to approach health communication as a team.

We often get together to discuss the best ways to approach health communication as a team.

Learning to write an engaging Healthy Tip of the Week required studying, believe it or not! Not only did I review the academic sources from my supervisor, but I also read through the hundreds of previously posted tips to gather ideas and become comfortable with the general format. Throughout my internship, I have enjoyed the challenge of parsing down language and learning to write so that the most important information is presented clearly right away. Through this, I’ve learned that less can be more.

As someone who is used to writing dense academic papers, learning to make my writing less formal was a challenge. Now that I have been with the Harlem Health Promotion Center for several months, however, I have a much better idea of why it’s necessary. It is truly rewarding to see someone read a health-conscious tip and finally understand what it means to have high blood pressure or why they need to take their medication. The empathy and understanding I have gained from this internship will stay with me into my courses at Mailman and my future career. In fact, I’ll be taking a Health Literacy course in the fall, and I already anticipate raising my hand a lot!

WhatWeDo

 

 

A Glimpse at D.C.’s Public Health Careers

By Whitney Peters, MPH ’15 in Health Policy & Management, MSW ’15 in Policy & Practice

My partner and I (and our dog!) moved from Fort Collins, Colorado to New York City two years ago, when both of us were starting our graduate studies at Columbia. We fell in love with the City and were drawn by the academics and the School’s large network.  Over spring break, the Office of Career Services delivered with Mailman’s first-ever Washington D.C. Career Week. The glimpse at careers in the D.C. area provided invaluable insight for us both, with me searching for a summer internship to supplement my dual degree and Zach transitioning into the workforce.

Peters Arrive in NYC

Whitney Peters and her partner Zach on the day they arrived in New York City.

I, and a group of about 50 students, participated in three full days of meetings, tours, and events, with many being hosted by some amazing members of the alumni network.  Visits included the Congressional Budget Office, U.S. Department of Health and Human Services, the State Department, the Food and Drug Administration, Kaiser Family Foundation, the National Association of County and City Health Officials (NACCHO), and many more! We each were able to customize our own trip from a broad range of options: we could visit agencies of interest in pre-organized groups, connect with alumni who work in fields of similar interest, and/or go to an office or organization personally.

Actually visiting offices provided us with insight into the culture, attitude, and environment of a place – key factors that are rarely available in a job description or on a website. As a young professional, getting a first-hand look at the wide array of work environments was invaluable. Something as integral as the issue or topic of focus is as important as employee relationships and the culture of an organization.

As part of our Washington Week, Zach and I also met with an alumna, Annette Ramirez de Arellano, DrPH’86, at the Smithsonian Castle Café just after she had finished a volunteer shift at the Museum for African Art. She has recently retired and is now freelancing in her spare time. Zach and I are both interested in this type of work as a means of pursuing personal interests while also providing supplemental income. We were happy and grateful to Annette for sharing a wealth of advice and information based on her extensive and impressive experiences in the field of public health.

U.S. Department of Health and Human Services

A group of us at the U.S. Department of Health and Human Services. Whitney is front and center – black dress, gray jacket – and her partner Zach is behind her in the second row. (Photo credit: Heather Krasna)

When my partner and I moved to New York City, we had plans to stay here after graduating.  But we, like many students interested in national level policy and programming, feel that the job opportunities in Washington, DC, are more in line with our career aspirations. Additionally, I recently received a Fisher Cummings Fellowship through the School of Social Work, which allows me to spend my final semester learning and working at a federal agency in D.C.

From a personal and social perspective, having never lived in Washington, DC, I have wondered what it would be like to live and work in the nation’s capitol. I worry that if or when I move I will miss the culture, food, streets, subways, and people that are so unique to NYC! Will I be trading in a city filled with personality and zeal for life for one filled with automatons and politicos?  Will I have to give up my Unlimited Ride Metro Card for a gas-guzzling car to get me to and from work?  Will my friends still want to visit as often if I no longer have Central Park and Broadway just steps from my front door?

Although I was not able to fully answer all of these questions following this trip, after just three days of bounding around the city, I was able to see many of the benefits and charms that the Capitol has to offer. In my free time I stopped in to visit several of the free museums along the National Mall, took a leisurely stroll along the beautiful Potomac River, and had a happy hour beer that was only $2!

To say the least, this has been one of the best experiences I have had outside of the classroom since coming to Mailman. In hope someday, when I am established in my career, I can return the favor to future Mailman students as they embark on their lives as public health professionals.

10 Communication Tips from a Biostatistician

by Joshua Kriger, MS ’14, in the Biostatistics Theory and Methods Program

Josh Kriger, MPH 14'

The days are over when a statistician sits in a back room tabulating data. The statistician needs to be a questioner with a passion for the truth and an expert communicator dedicated to efficiency and clarity.

During my time at Columbia, with the support of my colleagues and mentors, I was fortunate to participate in three separate studies in three different roles. I have been the chief statistician on a phase 2 dose finding trial, an associate statistician for the Statistical Analysis Center for Clinical Trials (SAC), and as a project manager on a service contract for a major pharmaceutical company. I loved the experience working in these clinical trials, and I want to share some of my insights from the experience.

1. Keep it simple.

Design should be as simple as possible to answer clinical questions. Beyond this, articulate assumptions for the trial and what will happen if those assumptions are not met.

2. Take your time when it is not intuitive.

Type 1 and type 2 errors are often misunderstood by people who do not have formal training. Take time to go over the basics. It all starts with the fundamentals of blocking and tackling.

Joshua_at_Work

3. Agree to disagree.

People often agree with each other not realizing they are talking about two different things. Just because a meeting was full of agreement does not necessarily mean the people involved were agreeing on the same thing. Don’t be afraid to disagree.

4. Speak plainly.

Biostatisticians, and statisticians in general, must be able to put things in plain language, not just rattle off obscure acronyms.Joshua_in_Class

5. Ask questions.

I love asking this last question of the day: “What have we decided and discussed today?” The investigator or clinician working with you should be confident in why the design or analysis choices are made while also being confident in articulating them to others.

6. Sensitivity analyses are key.

What happens if an assumption or target is not met? Example: What will happen if our projected recruitment rate is lower than expected? What if the effect size is not what we previously saw in research? It is important to see what can break and the implications for the research.Joshua&Seamus

7. Get to the heart of the question.

A Biostatistician should be able to articulate, identify and get to the heart of the clinical question. No amount of data (no matter how “Big”) should be substituted for taking the time to ask the right question.

8. Summarize key information.

How was recruitment? How long did it take to report events outside the norm? For each group involved with research there is a different set of priorities. Filter out information not needed to account for patient safety or to answer the desired research question.Joshua_Deviation

9. Respect data management.

Have a quality data manager. Data management is often the step in clinical research that limits the outcomes. Data management is the foundation of well-done studies. Some up front design work will save you multiples on the time invested when you are ready for project analysis.

10. Bring the statistician in during your early planning phase.

As soon as you start to conceptualize the question you want to investigate, call a statistician. The last thing anyone wants (funders, patients etc.) is to find out mid-way through, or worse, at the end of a project, that the data collected or design does not answer the desired central question.

Statisticians today have an ever-growing network of colleagues to learn from. These include other statisticians, clinicians (both those who understand statistics and those who don’t), budget officers, review boards, company representatives, patient representative organizations, and dozens of others. We need statisticians to not just be brilliant theoreticians, but also masterful in communicators. Statisticians who incorporate and understand these two concepts save you precious time, money, and countless headaches.

Classroom

Special thanks to Dr. Seamus Thompson, Dr. Bruce Levin, Columbia University Mailman School of Public Health, and the Department of Biostatistics.

Residues of my first semester at Mailman: Sticky Notes and Inspiration

By Elburg van Boetzelaer, MPH’15 in Population and Family Health with a certificate in Public Health & Humanitarian Assistance

Elburg_van_Boetzelaer_webIt’s snowing when I return to the U.S. after spending my winter break in the Netherlands. I’m sitting at my desk, surrounded by books, files, and handwritten notes: residues of my first semester at Mailman.

While attending lectures during my first semester and trying to take in the abundance of information, I got into the habit of writing down remarkable facts, numbers, and percentages on colored sticky notes, then sticking them to the wall above my desk.

MyInspiration

A random selection of facts I deemed noteworthy: “the poorest countries account for 56% of the global disease burden;” “deaths in low-intensity conflict states are often not due to violence, but are preventable;” and “the number one cause of death for children is diarrheal disease and can be prevented by effective water and sanitation efforts.”

It makes for a depressing wall, but glancing over that collection of posts encourages me to keep reading, studying, and writing, even when it’s past midnight and my brain is starting to show signs of overload. Those facts are the reason I decided to apply to the program of Forced Migration.

After earning a master’s degree in criminology from the University of Amsterdam, I moved to Southeast Asia where I spent three years working in Indonesia, Singapore, Thailand, and Cambodia. I worked for child protection organizations, mainly focusing on the elimination of the sexual exploitation of children around the globe. While I loved my work and fieldwork in general, I realized that, in order to grow and contribute in a more meaningful way to the field of child protection, I had to acquire practical skills that my criminology degree did not cover.

My decision to apply to Mailman’s Program on Forced Migration and Health was easy; the GRE proved to be more challenging. Somehow, I managed to brush up my high school math skills, pass the test, and submit my application before the deadline. Then the waiting began. Finally, in March, while riding a tuktuk through the center of Phnom Penh on a hot and dusty afternoon, I received the email saying that I was accepted to Mailman! I was screaming, yelling, laughing, and crying at the same time. Poor tuktuk driver; he must have been shocked by the amount of noise a petite blonde can produce.

The end of August was the big move. After living in Asia for years, feasting on rice and noodles, it was time to exchange life in a variety of polluted cities for life in The Big Apple, where I would feast on hamburgers and mac and cheese. I was ready for a new adventure and excited to become part of the class of 2015.

NewYorkWinter

And now here I am, looking at the snow outside of my window, thinking about the past months at Mailman and in New York. I’ve been challenged by professors, fellow students, and the authors of the many articles I read. Studying at Mailman has been a unique experience. Being taught by professors who combine teaching with ground-breaking research, while also being involved in the field, is such an honor. With every lecture that passes, I feel I that I am gaining so much knowledge, awareness, and new insight. One of the classes that incorporates the material covered in lectures is Integration of Science and Practice. During weekly meetings in groups of 20 students led by a professor, we discuss public health case studies, and its ethical dilemmas and implications. A great way to interact with peer students, apply what I learned in class and form my own opinions regarding public health issues that impact our everyday life.

With the second semester starting, as nerdy as it may sound, I can’t wait for it to get into full swing. The first semester consisted of the Core, courses that every Mailman student takes, regardless of their department or certificate. But from now on, the courses I choose will be department and certificate specific. In the case of the program on Forced Migration, this means that I will take courses like Investigative Methods in Complex Emergencies and Child Protection in War and Disaster. Just typing the titles gets me so excited!

BackToWork

This is what I came here for: soaking up all this knowledge, acquiring skills, learning from professors and students, and preparing myself for a professional life in the field of child protection and humanitarian assistance. I consider myself a very lucky person to be living my dream and to learn from the best. And I still have 1.5 more years of studying at Mailman in the program of Forced Migration ahead of me!

OutInTheCity

Report from the Philippines: Day Clinics in the Province of East Samar

By Tim Tan, MD, MPH’14 in Population and Family Health with a certificate in Public Health & Humanitarian Assistance and a Columbia University International Emergency Medicine Fellow

Following the devastation caused by Typhoon Haiyan/Yolanda in the Philippines, I joined a medical team deployed by NYC Medics, a disaster relief NGO based in New York City, and provided emergency medical care to hard-to-reach, small communities. Overall, the work put my Public Health and Humanitarian Assistance classwork into context in a practical fieldwork experience, from collaborating with local and NGO partners, to participating in OCHA cluster meetings, to prioritizing needs and providing care.

Our Mobile Model

Administering emergency medical care.

Administering emergency medical care.

True to the mission of NYC Medics, our medical team focused on providing care to remote locations through mobile units. On of our first excursion, we worked in a village on Homonhon Island, a small island 2-3 hours by boat from Guiuan which had had no contact with the rest of the country due to shattered boats and damaged phone networks.  With transportation assistance from US Navy helicopters, we ran a one-day clinic out of an unused hospital, seeing over 170 patients.

As expected, the team treated patients with infected wounds, infectious diseases with a high incidence of acute respiratory illness and pneumonia, and exacerbations of chronic illnesses such as asthma or hypertension. The other health issues we saw ranged widely—on one occasion, I played the role of dentist to extract a young boy’s infected tooth. On another occasion, the diagnosis was all-too-clear when a small girl threw up an Ascaris worm (an intestinal roundworm). A patient whom we identified with life threatening conditions—renal failure and pulmonary edema—was evacuated off the island to a referral hospital run by partner NGOs.

For staffing, we had a surgical physician’s assistant, a nurse from NewYork-Presbyterian, several paramedics, and myself, an emergency medicine physician. In addition, two nurses from the Department of Health in Guiuan joined us and provided tetanus vaccinations to our patients. One of the DoH nurses stayed behind to provide follow-up wound care to patients that we treated.

The navy forgot to pick us up that night, so we ended up camping overnight on the island before returning to Guiuan the following morning. The locals were more than happy to have us as our guests, however, so the impromptu stay went smoothly. It was a quick introduction to life on the ground.

Expanding Care Around Guiuan

After that first trip out, we continued to work with the US Navy and USAID to plan additional mobile medical clinics for different sections of Homonhon Island.  During this first week, the NYC Medics medical team essentially split into two groups.  I was the physician for the mobile team, and together with anywhere from four to seven other team members—physician assistants (PAs), registered nurses (RNs), and paramedics (or EMTs, emergency medical technicians)—we made several additional trips to Homonhon Island, providing medical care to communities that had not been reached since the storm.

While one mobile medical unit served Homonhon island, NYC Medics formed a second “land-based” mobile medical unit providing care to small communities surrounding Guiuan, treating from 130 to over 250 patients per day.  Medical complaints and diagnoses were similar, with infected wounds, respiratory illness and diarrhea, and untreated hypertension, diabetes, and asthma commonly encountered.

The city of Guiuan itself had its medical needs covered by a Doctors Without Borders (MSF) clinic and field hospital.  This field hospital served as our referral site for patients who were especially ill and needed to be evacuated from Homonhon Island for inpatient care.

Relocating to Hernani

During the second week of the relief mission, NYC Medics learned that several communities northward along the coastline had not received the same level of attention from relief agencies.  The team thus relocated to the towns of Llorrente and Hernani, where we continued to work using the same model of mobile and land-based teams.  Though the destruction in these areas was less severe, medical needs were comparable due to damaged infrastructure and limited access to personnel and resources.  Since the international community had a smaller presence in this area, we mostly worked with the mayor and a local doctor to identify communities in which to work.

I continued to work with the mobile team. One of our roles was to deliver care to people on an island that was only accessible by boat, and another community that could only be reached by a mountain hike over washed-out roads.  We hiked with all drugs, medical supplies, and clinic gear, rushing to beat the high tide.  It showed me how out of shape I am compared to the EMTs!  Around Hernani and Llorrente, the patient mix included more primary-care issues, but we continued to encounter a large infectious disease burden, as one would expect post-disaster, including acute respiratory infections and diarrhea.

Throughout our stay, each team saw between 100-300 patients per day, with a final day clinic of over 550 patients (with both teams involved). In total, we treated over 2500 patients, all in remote areas.

The Power of Partnerships

NYC Medics works with numerous partners to set up the day clinics and serve communities located outside of the NGO centers. During my time in the Philippines, the U.S. Navy provided us with transportation, USAID helped coordinate between us and the Navy, and MSF was a valued referral partner in Guiuan.  Many other wonderful collaborators assisted in numerous ways.

AmeriCares stands out as one of the most valuable.  They provided a truckload of essential medications and supplies to our team, which enabled us to continue delivering emergency medical care.  In a video that AmeriCares made during one of our trips to Homonhon Island, an AmeriCares colleague, Alex explains: “We were the first people to come to the community since the typhoon struck.  The team treated more than 100 patients, including a diabetic woman who was on the verge of losing her foot from a cut she got during the storm.” Watch the video “Isolated Village Gets Crucial Medical Care” from AmeriCares on Vimeo.

To read more about the NYC Medics partnership with AmeriCares and the ongoing work to help meet the needs of families suffering in the aftermath of the typhoon, visit this Haiyan/Yolanda webpage.

Makita Mo Mamaya (Farewell) to the Philippines

I am leaving to return to New York soon, but the international response to Typhoon is only just beginning. A lot has happened since I first landed in the Philippines. I will carry this experience back to the classroom and forward as I continue my career after graduation.

Photo credit: NYC Medics Operations Director, Phil Suarez

Caught in a Complex Emergency: The Realities of Post-Typhoon Haiyan

By Stephanie Lucas, MPH’14 in Epidemiology with a Global Health Certificate

Stephanie Lucas on Coron Island

Coron Island in the background just 5 days before Typhoon Haiyan hit the Philippines

From the Bohol earthquake just last month to the Typhoon Haiyan/Yolanda last week, it is heartbreaking to see how many natural disasters this country endures. I have a little over a month left of my three-month practicum in the Philippines with International Organization for Migration (IOM), one of the organizations involved in the risk reduction and response process in partnership with the United Nations action plan.

Safe in metro Manila, which the typhoon missed almost completely, I am saddened by the situation. Across the Philippines we estimate that there are 450,000 people in shelters and 1,790 in evacuation centers. Just last Tuesday I left Northern Palawan, specifically Coron. Like Leyte and Samar, it too was located close to the path of the typhoon and has been devastated by the storm. I heard from a friend I met there that many people are missing or dead and at least 50 boats were destroyed. Places that I had just visited and photographed (see below) were no longer accessible.  The large cross on the top of Mt. Tapyas fell down; the airport was out of commission; and the market was also crippled.

Mt. Tapyas

Mt. Tapyas

On Tuesday, I participated in a series of health cluster meetings at the Philippine Department of Health as a representative from IOM. We discussed how to assess the situation, identify the most vulnerable populations, and then organize, prioritize, and coordinate efforts to respond to the typhoon.

Continue reading