September 2019

Pediatric Global Health Newsletter

Photo by TREAT and Company

Note From Dr. Howard

Hi Everyone!

School has started for the children in our lives! Fall is in the air!

For immigrant children, the joy of school may be tempered with fear of deportation or the reality of detention even here in Minnesota. On the evening of September 11th, Drs. Calla Brown and Hannah Lichtsinn will lead us in a discussion of immigrant communities in Minnesota with a focus on coalition building and advocacy for immigrant children and their families.

Please make every effort to come - we'll have dinner and learn more about how we can advocate for our patients, who are new to the United States.

Hope to see you soon,

Cindy

Upcoming Events

Monthly Pediatric Global Health Track Dinner Meeting

Date & Time: Wednesday, September 11 — 6:30 p.m.—8:30 p.m.

Location: Dr. Slusher's house

Topic: Informal Coalition Building as an Advocacy Strategy with a Focus on Immigrant Cultures in Minnesota

Click here to RSVP

Research Lunch Meeting

Date & Time: Tuesday, September 17 — 12:00 p.m.—1:00 p.m.

Location: Wilf 3

Topic: Research Specific Aims Part 1: Identifying, developing and writing your specific aims for grant application. This is the most important page in your entire grant application.

Click here to RSVP

Social Public Health & Ghana's National Response to HIV

Date & Time: Tuesday, September 17 - 12:15-1:30 p.m.

Location: 2-690 Moos Tower

Speaker: Amos Laar, PhD

No RSVP required , free

Click here for more information

Click here to view our events for the year.

Residents Abroad

Sharmila Raghunandan and Nathan Wegmann – Kampala, Uganda 1/14/19 – 3/8/19

After a busy month at Saint Paul Children’s, Nathan and I set out to explore Kampala, the capital and largest city in Uganda. We arrived at Entebbe, a city 27 miles south of Kampala that was lush, green, hot and humid. We made our way on a busy highway to Kampala and were greeted by Stewart, a warm, kind and humble local who took care of the University of Minnesota house that brought together medical students, graduate students, residents and attendings from the Twin Cities and many other countries. Stewart introduced us to Mulago hospital (the largest pediatric referral hospital in East Africa with over 1500 beds and several sub-specialties) as well as many local treasures including Mama Box (one of the hospital cafeterias that served the best local food), Rolex (a popular street food that was an omelet wrapped in a chapati), Matoke (mashed plantains) and the Muzungu Market (market for foreigners). We were excited to experience a new country, culture, cuisine and a very different health care system.

My first day on the hematology ward at Mulago hospital was exciting yet overwhelming. I cared for over 20 children, nearly all of whom had sickle cell disease (SCD). I was alarmed that most of the children presented with debilitating sequelae of SCD including acute chest syndrome, stroke, seizures, dactylitis, priapism, osteomyelitis, leg ulcers and avascular necrosis. A large part of their treatment depended on whether the family could afford intravenous fluids, antibiotics, labs, imaging, surgery and follow up. The age at diagnosis, prophylactic treatment, complications and ability to access care were vastly different from those of children in the U.S. This motivated me to learn more about SCD and the causes of inequity in healthcare between low and high-income countries. I also began seeking out projects related to hematology and oncology and was able collaborate with Ugandan medical officers and attendings to complete a project related to SCD that aimed at assessing the validity of peripheral smears as a diagnostic tool for SCD.

I spent my mornings and afternoons on the hematology and oncology wards caring for patients and evenings working on the SCD research project. Over the next several weeks, I grew close to many children and their families, some of whom had very dismal diagnosis. A few memorable patients I took care of included: a 3 year old girl with relapsed Acute Lymphoblastic Leukemia (ALL) who had hyperleukocytosis (white cell count of 941 103/µL), anemia (hemoglobin of 4.9) and thrombocytopenia (platelets of 53); a 15 year old male with ALL and sever tumor lysis with hyperkalemia (potassium of 6.7) who unfortunately couldn’t afford any treatments; a 1 year old boy with metastatic anaplastic wilm’s tumor and severe malnutrition who had spillage of her tumor when he underwent surgery to resect his abdominal mass and subsequently passed away one night in the absence of attendings, fellows or residents; an 8 year old female with Acquired Immune Deficiency Syndrome who was diagnosed with Kaposi sarcoma who slowly improved over the course of a month; and a 4 year old male with relapsed AML who needed BMT, but had to find a way to South Africa or India for treatment. I can continue to list the innumerable encounters with patients and their families, but what was most remarkable was their sense of optimism, gratitude, courage and resilience.

To sum it up, the last 8 weeks have been a melting pot of joy, tears, successes, losses, excitement, fear and frustration. It has been an incredible experience and I feel fortunate to have played a role in the lives of the most irrepressible children, to have made long lasting relationships with medical officers, attendings and friends and to have had the chance to explore other neighboring countries including Rwanda, Kenya and Egypt. I also had the opportunity to present at the Society of International Pediatric Oncology Africa meeting in Cairo, that brought together health care professionals from all over the world with a common goal of advocating globally for children with cancer and promoting equity of care to every child.

Faculty's Corner

Note from Dr. Kristina Krohn regarding her time in Laos

Looking at her foot I knew that Noi had osteomyelitis. From her story she had osteomyelitis for at least 3 months. Sitting in the rehab center, I had no authority to make her do anything. All I could do was talk. I talked to the disability center’s staff and the head nurse. I left my number for the doctor to call me. To everyone, my message was the same. Send Noi to Mahosot Hospital, to the Infectious Disease Ward and have her seen by Dr. Bandith – no one else.

In 2015, Dr. Bandith was one the first pediatricians in all of Laos to complete advanced fellowship training. Health Frontiers, the nonprofit I worked for, arranged and supported Dr. Bandith and 3 other pediatricians to go to fellowship training in Thailand. Dr. Bandith and his 3 colleagues already knew Health Frontiers well as Health Frontiers had worked with the Lao government to create the residency program that he completed.

I knew Dr. Bandith as an pediatric infectious disease doctor and one of the teachers in the residency program where I also taught as the Country Representative for Health Frontiers. Health Frontiers was formed in 1990 by request from the lone pediatrician in Laos, a country then of 5 million people. After working with government for 8 years, the initial residency class started in 1998. At that time the Health Frontiers Country Rep coordinated the entire residency program, from creating schedules to writing the exam questions to creating the selection process. Now with almost 150 pediatricians in the country, my role was more advisory and teaching.

Walking down the hallway to start rounds I was happy to see Dr. Khammtoun, one of the 3rd year residents looking for me. “Noi came” he told me, and we rushed to see her.

Every day I rounded with the residents, only seeing “interesting patients”, as they had already rounded with their Lao attending. When the residency started in 1998, the Health Frontiers staff did a lot of the bedside and didactic teaching as the Lao Pediatricians (by then there were 5) had to take care of patients and do all the normal hospital admin work. But when I was there, 2016-2017, there were plenty of pediatricians to do most of the work and teaching. I spent my time on “interesting patients” and looking for knowledge gaps in the curriculum.

Dr. Khammtoun presented Noi’s case and we talked about best practices for treating chronic osteomyelitis. Dr. Khammotoun and Dr. Bandith had done an excellent job with antibiotics and arranging for a bone biopsy. With Dr. Bandith, a teacher who could teach in Lao Language and stay in the country, I wasn’t really needed.

Which was the whole point. Of the almost 150 graduates of the pediatric residency program, one has died. Two have now retired. But the remainder all work in pediatrics in Laos. There are more pediatricians in Lao who can teach and provide care and do all the admin work that needs to be done. Still 150 pediatricians for a country of now 7 million people, it is still not enough.

While there is no longer a need for foreigners to provide the administration of the residency program, there is room now for partnerships in a manner different than before. The Lao doctors are working on ensuring that quality pediatric care is distributed throughout the country. Instead of working together as a foreign expert talking to a non-expert local, I am happy to say that I have almost 150 expert colleagues in Laos. I’m looking forward to continue to work with them in the future.

If you have interest in visiting Laos, please contact Kristina at kroh0040@umn.edu

Resident Spotlight

Deeksha Borka, MD - Pediatric Resident PL1

Deeksha Borka is a pediatrics intern from India. She went to medical school at St. Petersburg State Pediatric Medical University in St. Petersburg, Russia where she had the opportunity to train at community hospitals. Afterwards, she moved back to India and worked with Hirabai Cowasji Jehangir Medical Research Institute (HCJ-MRI) on projects addressing malnourishment among children in Karegaon, a rural village in the western region of the state of Maharashtra. She worked with a team that specifically provided nutritional supplements to child attending school in the village, and she also studied the effects of vitamin D supplementation on rates of infection among this population. She also worked as a primary care pediatrician with the NityaAsha Foundation which serves children with diabetes mellitus, type 1 who live in low-income communities. She currently is working on a study looking at the use of a CT protocol in children suspected to have appendicitis in the ED setting. She is also working on a dual masters program for her MPH and MSc in Behavioral Health at the University of San Francisco. She is passionate about global health in pediatrics, use of imaging in low resource settings, health equity among marginalized populations and people of color.

Deeksha is in the first row on our right of the lady in the jacket

Favorite quote: It is something that I have followed for a long time.

“When I dare to be powerful – to use my strength in the service of my vision, then it becomes less and less important whether I am afraid.”

-Audre Lorde

Favorite travel destination: Santorini, Greece

What the world needs more of: Equality and Acceptance

If you weren't a physician you would be: Chef

Fellowship and Career Opportunities

What: Global, Rural and Underserved Child Health Fellowship

Where: Department of Pediatrics at the University of Utah School of Medicine and in partnership with the University of Rwanda/University Teaching Hospital of Butare (Rwanda) and Navajo Area Indian Health—Chinle, Arizona.

Application Due Date: October 1, 2019

Dates: July 1, 2020 through June 30, 2022.

More information: https://tinyurl.com/gruchflyer