October Global Health Readings

For those in the Boston area, the MSF exhibition Forced from Home is an engaging discussion about the plight of displaced peoples throughout the world. It’s a 45-55 minute tour, you can drop in or reserve a spot ahead of time, and it includes both a 360 degree film of various refugee camps as well as multiple short presentations around different aspects of life for displaced people. Worthwhile.


A piece discussing interventions around access to medications – I thought the MSH intervention in Tanzania parallels the work domestically in academic detailing in some interesting ways.
The annual TB report from the WHO (which we’ll be discussing amongst the GH pathway people later this week).  Highlights include the improving ability for diagnosis and treatment, counterbalanced by rising resistance as well as difficulties in prevention and case detection.
Great piece from BMC’s own Nahid Bhadelia on a common problem in LRS, where donated medical equipment lies broken and subsequently unused.
Posted in BMC

Evolution and Vaccination

While on vacation last week I was a guest teacher in my friend’s advanced biology class. They were doing a unit on evolutionary biology and their teacher, my friend, had asked them to conceptualize a pathogen that would be evolutionarily successful. They had been learning about the “trade off hypothesis” (1) which is the idea that for an organism to be an evolutionary success it must balance virulence (harm inflicted on a host) with ability to transfer to a maximal number of hosts. For example, a pathogen that was highly virulent would cause a huge amount of harm to the host, in some cases killing them, and thus creating a dead end in its evolutionary goal-> to make as many copies of itself as possible (we will ignore the ability for the continued infectivity of bodies after death for this purpose), verses pathogens that take on the goal of minimal virulence for increased transmission, for this I like to think of rhinovirus which causes the common cold. Sure you feel a little sick when you get a cold (its virulence) but not sick enough to avoid interacting in the world and spreading the virus.

While visiting the classroom I decided to tell them about two historical pathogens that had wreaked havoc on the world in the not so distant past: Polio and smallpox, in order to illustrate different evolutionary strategies taken by each virus and why we were able to easily eradicate one (smallpox), while its taken us longer on the other (poliovirus).

Smallpox had plagued mankind for millennia (it was endemic in parts of Asia as far back as the 1st century CE) and it was incredibly virulent (mortality rates ranged from 30-50%) . Most of the students had heard about smallpox but didn’t know the details of its infection, or how it spread (respiratory); what was funny to me was that the students all assumed that the mortality rate was much higher (a lot guessing around 90%) and I had to explain to them that a mortality rate of 30-50% was indeed very high and that a 90% mortality rate would be an evolutionary dead end for any virus. The last wild type smallpox case was in 1977 in Somalia (2).

The reason the campaign against smallpox was so effective was not only because there was an effective vaccine, but also due to the nature of the virus itself. Smallpox does not have an asymptomatic carrier state, i.e. you are only able to spread it once you start experiencing symptoms. The incubation period is 10-14 days, during which time you are not infectious, then you progress to a pre-eruptive stage lasting 2-4 days which comes with symptoms of high fever, headache, myalgias, nausea and vomiting not unlike the flu. When i asked the students what they would do if they started feeling like this most of them answered, i would stay home in bed, which is exactly the point. Smallpox is so virulent that people will stay home and avoid going out into the world and spreading the illness. The point at which smallpox reaches its peak infectivity is during the rash stage and at that point the cat is out of the proverbial bag. Another characteristic of smallpox that made it relatively easy to eradicate was that its only hosts were humans. Unlike other viruses (such as ebola, or rabies) there are no other organisms that variola infects and there is no independent vector spreading the disease (as with plague). Finally, the vaccine for smallpox worked, and it worked well. In fact if someone has been exposed to the virus, if they receive the vaccine within 3 days they are likely to either not become ill, or experience a much less severe form of the illness. I used this example to illustrate to the students why a highly virulent virus would not necessarily be the most evolutionarily beneficial strategy (all info 2).

Contrast smallpox with polio where 90-95% of infections are asymptomatic, which means that people are shedding the virus without knowing it. Another thing that shocked students was how low the paralysis rates were (along the lines of 0.1% of infection). They had assumed that because they had all heard about how horrible poliovirus was that the virulence must be so much higher (3). I explained to them that this asymptomatic infection was one of the reasons why it was so difficult to eradicate poliovirus, i also explained that the nature of the vaccine itself contributed to the persistence of the virus (though we are now finally approaching true eradication). Polio dropped from 350,000 cases in 1988 to 1,000 in 2014, a monumental improvement due to the Global Polio Eradication Initiative (started in 1988). The initial goal of the Global Polio Eradication Initiative was to eradicate polio by 2000, the organization is spearheaded by WHO, Rotary international, CBC, UNICEF and The gates foundation. They used four strategies to attain this goal, first they instituted routine infant immunization programs globally, then they added additional immunization campaigns for age groups (say everyone under 5 for example) regardless of whether or not they’d already been immunized. They had active surveillance for paralysis and any time there was an outbreak they would travel to the location and re-immunize the population with OPV which stopped the spread (3).

There are two kinds of vaccine, an injectable killed virus (introduced first) and an oral attenuated viral vaccine. The oral vaccine was thought to be better because it induced a stronger immunity particularly in the gut (where poliovirus replicates first), it was easy to administer (all it required was a drop of vaccine on the tongue), and it was 10 times less expensive than the injectable variety. Essentially the perfect vaccine for a global program. One of the downsides of the oral polio vaccine is the fact that it causes paralysis in 1 in 2.5 million administrations (3). Which sounds like great odds until you factor in that there are 6 Billion people in the world and that someone who becomes infected with the active virus starts to shed it in their stool. Then you have a localized polio outbreak which is exactly what happened in The Dominican Republic and Haiti in 2000. In that outbreak there were 21 cases of paralysis and 2 deaths which were later found to be attributed to a vaccine derived strain of polio (4). My own uncle developed polio after receiving the oral polio vaccine in the late 60s (he later made a full recovery) but he accounted to me how one morning my grandmother told him to straighten up (She’d noticed his gait was crooked) and he found he was unable to. A better form of the inactivated vaccine (given as part of the tetanus/pertussis vaccine) became available in the 1980s and by 2000 everyone in the US had switched over to the inactivated, injectable form (4).

The question of the social justice of the continued use of the oral polio vaccine is interesting. OPV provides better immunity to poliovirus overall and decreases the spread when administered in an outbreak (however the ability of the vaccine to work is limited by the presence of healthy gut tissue able to mount an immune response which is limited in areas of chronic diarrhea and enteritis (3)) and is easy to administer, however the conversion to active form of the virus is a serious problem as it propagates the infection. As part of the The Polio Eradication & Endgame Strategic Plan 2013-2018 WHO is in the process of phasing out routine OPV (oral polio vaccine) in favor of the Inactivated, injectable variety (5). Polio has represented a formidable foe to global health, due in part to its evolutionary strategies. Each year as the number of cases of poliomyelitis drop we look forward to a time when we can finally say we were able to eradicate it, we’re not there yet.

  1. “Virulence Evolution”: http://public.wsu.edu/~broosien/VirulenceEvolution.html
  2. Up To date article on smallpox http://www.uptodate.com/contents/the-epidemiology-pathogenesis-and-clinical-manifestations-of-smallpox
  3. Up To date article on poliovirus http://www.uptodate.com/contents/global-poliomyelitis-eradication and http://www.uptodate.com/contents/polio-and-infectious-diseases-of-the-anterior-horn
  4. http://www.npr.org/sections/goatsandsoda/2015/11/10/455348658/the-oral-polio-vaccine-can-go-feral-but-who-vows-to-tame-it
  5. http://www.euro.who.int/en/health-topics/communicable-diseases/poliomyelitis/news/news/2016/04/poliomyelitis-polio-and-the-vaccines-used-to-eradicate-it-questions-and-answers#opvout
Posted in BMC

Hopeful for a Quality, Quality Revolution

Help more than hurt.  Choose partnerships over charity. Create sustainable solutions rather than temporary relief. These are familiar themes at global health conferences around the world. Interestingly this month’s issue of Lancet Global Health features a work by Kruk et al that draws us to consider, Quality Improvement (QI), a measure I hear much more often discussed at hospitals close to home. Indeed, U.S. institutions are placing an ever increasing emphasis on QI. Even my own training institution has developed a “QI pathway” for interested residents. Kruk et al propose the need for a Quality Revolution in Global health. We’ve realized it isn’t just about trying to practice in low resource settings, but on finding ways to ensure that the care provided is truly improving health outcomes. It would seem that quality improvement is indeed a global health issue, so where did QI come from? Since the Institute of Healthcare Improvement’s (IHI) landmark To Err is Human failures of healthcare have been a focus for hospitals and policy makers (2). Since that time the IHI has developed six principles that they believe should be used to guide health systems and improve quality. The IHI’s principles demand for care that is safe, effective, patient centered, timely, efficient, and equitable. Kruk et al sought to apply these quality dimensions to countries in sub-Saharan Africa. The authors selected outcomes they felt were reflective of at least one of these six dimensions. For example in “safety” they chose a metric like “facility has water on site nearby” or “effective” metrics like how many women aged 18-69 had received a pelvic exam. In this later measure they highlight that only 18% of women received a pelvic exam. They infer that yes there may be access to a clinic for these women, but that it wasn’t effective because the women weren’t given a proper exam. This is where I worry we fall short in our assessment on QI. Before knowing if this was truly a quality measure of the health center I would want to know of the women who did have an abnormal pelvic exam have access to the subsequent treatment. Perhaps practitioners in these clinics weren’t resourced with the solutions to the pathology they might find. Would I want to screen a woman for a cancer I had no treatment for?  
It has been my high-resource experiences that have led me to be skeptical of how we measure QI. One area of quality care across institutions in the U.S. is a well-documented code status. The idea is to prevent an invasive and painful attempt to save a life that may be against the patient’s wishes, beliefs, or clinical situation. On the surface this makes a lot of sense. Yet as I write this one of my overnight resident colleagues is surely trying to discuss the idea of a code status with someone’s admitted grandmother. Our grandmother is inevitably tired from the day in the ED on top of feeling very ill or in pain. She has met six doctors for the first time today and now appears my co-resident asking at 2:00 AM all of the same questions…and just at the end “ma’am what would you like us do if your heart stopped?” For many patients this is first time they’ve been asked this question. Yet, every patient will have a verified code status by the time I arrive tomorrow morning. Did the quality of our admissions improve? What was the quality of that code discussion and how much time could the overnight physician dedicate to that encounter. Our measure of verified code statuses looks better but I’m not so sure about the quality of care. Whether local or global we unquestionably need to seek opportunities to improve the care we provide. In this way I’m a big fan of Quality Improvement. I only hope that our “quality revolution” in global health is a mindful pursuit because the health of the world’s most vulnerable populations depend on it.
(1) Time for a quality revolution in global health. Kruk MELarson ETwum-Danso NA.
(2) Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century.National Academy Press, Washington, DC; 20
Posted in BMC

September Global Health Readings

An opportunity for trainees and faculty alike to submit essays for a CUGH contest – prizes include money and waived registration at the conference.  Consider submitting a piece (deadline Dec 4th).
A great piece from the BU SPH Dean discussing public health in a US (and a bit global) context.  He does a great job of reviewing the big picture data around US health and health expenditures in a concise and nice fashion; worth a quick read.
Ongoing coverage of the polio outbreak in Nigeria. A nice continuation of the case study we reviewed in India.
Sri Lanka has eradicated malaria, which is an impressive feat.  We knew it was feasible – the US itself did so last century – but to my knowledge no other countries have done so in the last few years.  While the eradication agenda presently focuses heavily on polio and to some degree measles (as well as guinea worm and other NCDs), malaria has been floated as a disease that could eventually be eradicated, though the tools for this are presently lacking.
Posted in BMC

Global Health Blog 2.0

Minasan, Kon’nichiwa!

I wanted to be the first to let you guys know that we will be now be updating our blog every 2 weeks with Global health topics and miscellaneous concerns. The goal is to have a new blog post out on the 1st and 3rd week of every month, starting with this post.

I am very excited to see how much interest we can gather for our global health endeavors. To that extent, I am also eager to recruit guest bloggers outside of our global health pathway residents, at BMC or otherwise, to blog about topics relevant to global health. Please subscribe to our blog, give us feedback and help us build a bigger online presence.

Now, back to your previously scheduled blogging.



If you haven’t already guessed, we’ve all returned from our global health trip to India, safe and sound. Even better, I did not contract dengue fever (this time).

Our trip was enlightening and exciting. Coming back to my home country and observing medical care in India, after a year away in the US, gave me a new perspective on things. It deepened my interests in cost-effective care, and my desire to practice equitable health.

2016-07-24 12.12.22

Obtaining perspective

We had a number of intense discussions and debates on topics ranging from the actual definition of global health,  the stakeholders that determine global health funding and care delivery, disease profiles and historical trends of diseases, and, the future of global health.

It was a grounding experience, that has left me with the essentials to begin to carve out a path towards my intended career in global health. For this, and many other reasons, I hope future residency applicants interested in a career in global health, choose BMC.


But I digress.

One of the things I’ve decided from this trip, is that I need to choose my words and actions carefully. The term used to describe what I thought was global health has changed frequently. Terms such as global health, local health and international health have been throw around in the past, and, in our discussions. I believe that what I intend to practice, is equitable health. I want to be able to provide equal opportunities in health care, i.e, to attempt to level the playing ground wherever help is needed to achieve that.

I am interested in a career in equitable health focused on obtaining renal replacement therapy where it is inaccessible. I envision that I will one day learn to place peritoneal dialysis catheters to start peritoneal dialysis in resource-limited settings, and eventually develop peritoneal dialysis centers that are self-sustained by the people that live in that country/region. I plan on spending the next few years of residency and fellowship, trying to figure out the best way to make this possible.

I will have more information on this, and other global health endeavors in nephrology, in the coming months.

For now, I will leave you with a picture of us on a swing in my home in Trichy

2016-07-29 19.24.40

From left to right: My grandmother; Andrea; Jocelyn; Ed; Me (Yuvaram)


Until next time!



P.S: My next topic will be Part 2 of the Medical Education System


Posted in BMC

August Global Health Readings

Starting next month, the residents in the BMC IM global health pathway will be publishing pieces every two weeks on topics in global health. Should be quite enjoyable!

A brief piece touching up quality in global health and summarizing several other papers within the same issue. I do think that improving delivery and implementation is a hugely important in global health – perhaps the most important at this particular moment – and that future programs will necessarily have a heavy focus on this.
Long piece focused on Jim Kim’s work at the World Bank – nicely lays out the changes he as an on-the-ground development sort is trying to actualize at an institution that does not have a strong history of working in that area.
Resurgent polio in Nigeria – as we discussed on our global health trip, finishing off the eradication process has proven to be very difficult.
A difficult situation in Haiti, where striking residents are holding out for a living wage and better working conditions – fair complaints – but as detailed, are leaving the health system without doctors to care for an already underserved population. No easy answers to this problem.
Posted in BMC