on the cover >>>
Diabetes prevention poster for
Cambodian immigrants in Con-
necticut. More information can
be found on our cover story.
Newsletter of Committee on Global Public Health Medical Student Section of the American Medical Association
publicly
in this issue >>>
Metta, Karuna, Mudita, Uppekha: My intern-
ship experience with a Cambodian Health
Organization
Lisa DiFedele, University of Connecticut
School of Medicine
Addressing Chronic Disease is Essential to
Achieving Millennium Development Goals
Nneoma Nwachuku, University of Connecticut
School of Medicine
Stomping out the embers of HIV in the United
States
M. Ricks, Harvard School of Public Health
Publically Speaking, the newsletter, is a fre-
quent periodical, sponsored by AMA-MSS
Committee on Global and Public Health (GPH.
Throughout this upcoming year, several medi-
cal students will be placing their ink to the pa-
per – focusing on the health care needs and
development of countries and regions around
the globe. We aim to bring much needed atten-
tion to current health care issues within and
beyond the American border.
winter 2010-2011
speaking
Metta, Karuna, Mudita, Uppekha
Internship experience with a Cambodian Health Organization
Medical student, Lisa DiFeDele, shares her internship experience at the Khmer Health
Advocates (KHA) in West Hartford, CT. Her work with KHA exemplifies how budding medi-
cal professionals can make an impact globally by acting locally. For more information on
KHA, check out http://www.khmerhealthadvocates.org. You can also find them on Facebook.
The day I began my internship this summer takes into account the special needs of the
I was welcomed with a home cooked meal Cambodian refugee patients. They lived
of chicken curry soup covered with basil, through a genocide, have traumatic brain
limes, and bean sprouts. The entire office injuries, have increased rates of many
joined to eat together and then walk around chronic diseases, and speak another lan-
the neighborhood together. This was a guage so foreign to me that over a few
way of living their health promotion curric- weeks I only learned one phrase. They live
ulum entitled Eat, Walk, Sleep. The organ- by a code of morals that encompasses Met-
ta(mercy), Karuna(compassion), Mudita
ization was the Khmer Health Advocates
(KHA), based out of West Hartford, Con- (joy), Uppekha(looking close and staying
necticut, and one of about 20 Khmer or- calm).
ganizations in the US. The organization is
Story continued on last page.
headed by Theavny Kuoch, a petite Cam-
bodian woman with a great vision of inte-
grated care for all Cambodians. The or-
ganization has taken on the monumental
task of creating and implementing a med-
ical home for the 300-400,000 Cambodi-
an refugees living in the US. This medi-
cal home model includes Community
Health Workers (CHW), telemedicine (a
system that connects workers in the field
with providers in the office via webcasts),
and electronic health records. The
APRN, Mary Scully, who is one of the
team responsible for the inception of the
program has labeled the care trauma in-
formed care. This trauma informed care
 interim 2010 >>>
Second-year University of Connecticut medical
student, Katherine Wonneberger, at maternal-
and-child health facility in Haiti. Her summer re-
search project, “The Effects of Migration on
Women’s Breastfeeding Behavior,” earned her the
Arnold P. Gold Foundation Student Summer Re-
search Fellowship.
Addressing Chronic Disease is
Essential to Achieving Millennium
Development Goals
Developing nations find themselves in dou-
ble jeopardy - battling acute infectious dis-
eases while remaining horribly unprepared
to face the rising threats chronic disease
such as cardiovascular disease, cancer, mo-
tor vehicle accidents, and far-too-long ig-
nored - mental illness. Large-scale disease-
centric interventions, at times, serves to
weaken overall health infrastructure, placing
focus (and funding) on one or two diseases
to the neglect of others - most oftentimes
non-communicable or chronic diseases
(NCDs).
The eight Millennium Development Goals
are targets set by member states of the Unit-
ed Nations to diminish global inequalities in
health and economics 2015. Successful
completion of the Millennium Development
Goals (MDGs), mildly stated, would be akin
to achieving world peace. As evidenced by
the conclusions emanating from September’s
United Nation’s Summit on the Millenium
Development Goals, the world is falling
short of achieving the aims of this lofty char-
ter.
In the research article, Drivers of Inequality
in Millennium Development Goal Progress:
A Statistical Analysis,‖ Oxford University
sociologist, David Stuckler and colleagues,
found that high NCD burden served as a
major barrier to achieving the UN's Millen-
nium Development Goals (MDGs) in indi-
vidual countries. It is important to note that
while the MDGs addresses diseases such as
HIV and tuberculosis, NCDs remain glaring-
ly absent from its health agenda. Stuckler’s
study found that a reduction in NCD burden
by 10% was nearly the equivalent to a 40%
rise in GDP (or at least five years of eco-
nomic growth in developing countries).
Continued neglect of NCDs in low to middle
income countries stands to impede any fu-
ture progress towards achieving the MDGs.
In fact, consider NCDs as the latest addition
to the category of Neglected Tropical Dis-
eases (NTDs). The study highlighted the fact
that NCDs plays an important role in the
complicated relationship between poverty
and health and as a result, greater emphasis
should not only be placed on addressing
NCDs, but health systems as a whole.
Nneoma Nwachuku, MPH, is a second year
medical student at the University of Connecti-
cut School of Medicine. She is a committee
member of GPH.
Stomping out the Embers of HIV in
the United States
Graduate student, M. Ricks, argues that the current HIV testing policies are ineffective and
should be replaced by universal opt-out testing to further drive down infection rates and increase
identification and subsequent treatment of HIV+ persons.
For years nobody thought that such a sweet
unassuming woman could harbor such deadly
secret. The problem was she didn’t know she
had one.
Ms. A.* had never been offered an HIV test
before because she was considered very low
risk. She had only one sexual partner in her
life. As an HIV counselor in the Emergency
Room, I was the first to offer her a test. The
secret was finally out: not only was she posi-
tive--she had full-blown AIDS.
While public health interventions and Highly
Active Antiretroviral Therapy (HAART)
have been cooling the red-hot fire of a once
blazing HIV epidemic, its embers have far
from fizzled out. The U.S. Centers for Dis-
ease Control (CDC) reports that of the 1.1
million people in the U.S. living with HIV,
more than 250,000 (25%) are unaware of
their infection. These individuals are not
even afforded the opportunity to receive the
treatment necessary that can prolong quality
of life. Up to a third of those who do find out
their HIV+ status do so too late—within 12
months of receiving an AIDS diagnosis.
This tragedy is compounded by the reality
that undiagnosed individuals are less likely to
engage in risk-reducing behaviors than those
with known HIV+ status facilitating trans-
mission of HIV to others. We quote stable
rates, but often downplay that someone new
in the U.S. becomes infected every 9½
minutes.
With new infections and inadequate identifi-
cation of positive individuals, the current
policy surrounding testing is ineffective.
Why aren’t more people getting tested?
First, HIV disproportionately affects certain
marginalized, often minority, populations
with Blacks (50%) and Hispanics (17%)
comprising the majority of new cases. Such
disadvantaged individuals tend to have di-
minished access to healthcare, testing, and
counseling opportunities.
Second, targeted testing misses the mark. By
categorizing ―high-risk‖ people, we fuel stig-
ma associated with HIV testing and create
barriers to testing. People are also likely to
lie about (or even misperceive) their risk fac-
tors. Therefore, they may neither ask nor be
offered a test by their provider(s).
Furthermore, many people falsely assume
that having been to the doctor’s office and
not being told that they have HIV means that
they probably got tested and that no news is
good news. With the exception of many pre-
natal care programs, HIV testing is an opt-in
process and you must be notified explicitly of
testing before administration, often in the
form of written informed consent. Thus,
signing and identification are also deterrents, Fabulous Find
as many people don’t want record of their
participation or results.
Finally, fear still consumes people when it Updated every three years, the 82-page Phar-
comes to HIV testing. Despite education
efforts, misconceptions still hold that an HIV macological treatment of mental disorders in
case today is the same death sentence it was primary health care manual provides the clini-
back when it first emerged in the 1980s. cian with evidenced-based information for the
The list of barriers goes on, but an effective administration of pharmacological treatment
way to stomp out these embers is to offer
HIV tests more universally through an opt-out to people with mental disorders in low-to-
process. middle income families. Resource is published
In addressing lack of access to healthcare by the World Health Organization and both
services, the CDC actually issued recommen-
dations in 2006 to offer universal rapid test-
English and Spanish versions of the booklet
ing and counseling in the Emergency Room can be found at:
(ER). This is often the only point-of-care for
http://www.who.int/mental_health/manage
many marginalized patient populations, plus
many early-stage and late-stage cases mani- ment/psychotropic/en/index.html
fest themselves in this environment.
The ER, however, is only a start. In the doc-
tor’s office, a rapid test could be performed
when taking vital signs. Or, a traditional test
could be ordered along side a pool of other
samples, much in the style of blood banks
that test for HIV.
These are facts that all individuals should know.
By implementing these recommendations
through universal opt-out testing in all appro- With early diagnosis and access to care and
priate healthcare environments, we avoid services, HIV has become a much more man-
glossing over unsuspecting infected individu- ageable chronic disease with infected people
als and increase the frequency and normalcy living very normal and healthy lives for years.
of testing. More importantly, we reduce stig- However, adequate knowledge and empower-
ment through education and testing are critical
ma associated with HIV testing, dialogue, and
to prolong the quality of life of infected persons
status disclosure.
and reduce infection rates.
Coupled with increased testing, it is equally
important to scale up current education and
prevention efforts. I was surprised to learn M.Ricks is a current Masters degree candidate at
that a number of my youngest adult patients the Harvard School of Public Health. Prior to
matriculation, she served as a research assistant in
(statistically, the highest risk group) really did
the Emergency Department of a major Boston
not know much about HIV. Patients should hospital, testing and counseling hundreds of pa-
be made aware of the benefits of testing, tients.
treatment, and early diagnosis. For example,
the chance of an unborn child of an HIV+
mother acquiring infection drops from 25% to
less than 1%--if the mother is tested and sub- *Name has been changed.
sequently receives appropriate medication.

who are we?
Finding An Agent That’s Right For You
The AMA-MSS Committee on Global and Public Health (GPH) is responsible for re-
viewing current domestic and global public health issues and educating medical stu-
dent members of the AMA on these issues. GPH also seeks to involve medical students
in public health initiatives by facilitating chapter-level implementation of public health
projects.
(Metta, Karuna, Mudita, Uppekha, contin-
ued from front page)
While eating lunch with chopsticks a bottle
of sprite was knocked over. Ouk, a 50 year
old community health worker who lived thru
the Khmer Rouge quickly exclaimed: ―Pol
pot did it‖, and the entire table burst into
laughter. Mary then explained that we need
to talk about the trauma our patients have
experienced, she stated ―Trauma is crying,
laughing, and while objectifying trauma, it
can seem funny at times.‖
Throughout my few weeks at KHA, we saw
patients at the office and at their homes.
Visits in the field included medication ad-
herence visits with a pharmacist, and CHW
visits, which encompassed all aspects of the
individuals well being. Mental health visits
were completed in the office in West Hart-
ford or Danbury and were done by the resi-
dent psychiatrist, Dr. Miller. These visits
attempted to determine level of coping with
previous trauma history as well as eliciting
more of the trauma story.
The medical conditions of the patients I saw
began with PTSD, TBI, diabetes and never
really ended. Several of these conditions
were related to poor mental health status.
These diseases are worsened by the in-
creased issues with adherence which may be
rooted in underlying cognitive deficits, sec-
ondary to mental health issues. Often Cam-
bodian patients need medication instructions
repeated to them on numerous visits and
often even this is ineffective. In one house-
hold in an attempt to get a woman to regu-
larly check her blood sugar we placed a pic-
torial poster on her wall. The pharmacist
told me of one patient who routinely empties
her pills into a bowl and just takes a handful
when she feels like it.
My time at KHA culminated in a network of
friends dedicated to improving the health of
the Cambodian community thru hardwork
and specific programming but also thru
laughter and togetherness. The clout of KHA
and the warmth and strength of it’s health
workers was palpable my entire time there.
Write for Us
Have an interesting article, experience or
picture to share? We are currently looking for
public health related articles for our next is-
sue, written for and by medical students.
To submit, please contact newsletter editor:
Nneoma Nwachuku
nnwachuku@student.uchc.edu
I am excited to see the National Cambodian
Medical Home Model move forward.
In the time since I left KHA a tragedy has
occurred in the Khmer population. A grand- about us >>>
mother, who survived Pol Pot, and lived
with 11 of her family members in Seattle
went on a shooting spree and after killing Meet the 2010-2011
her son-in-law and numerous grandchildren,
shot herself. During the tragedy she never GPH Committee
recognized her actions but instead was con-
David Dornbos
vinced that an external being was complet-
ing the shootings. The tragedy is augmented Wayne State University, Class of 2012
by the fact that she was diagnosed as schizo- Chair
phrenic. Stories like this where the tragedy
is rooted in the history of trauma are espe- Andrew Osten
cially trying for the Khmer population. In Tufts University School of Medicine, Class
order to decrease the incidence of these of 2012
events we must educate providers on the Vice Chair
special needs of this population.
Andrew Bucholz
Prior to medical school, Lisa DiFedele received UMDNJ School of Osteopathic Medicine,
her MPH from Yale in Epidemiology of Microbial Class of 2013
Disease. She has worked in public health infec-
tious disease research and was able to travel
extensively in Latin America and in Africa. She is Olutoyin (Toyin) Okanlawon
an active member of UCONN’s Urban Service Vanderbilt School of Medicine, Class of
Track which produces future healthcare provid- 2011
ers sensitive to needs of vulnerable populations
She is involved in the AMA and Connecticut State
Medical Society. She is former co-chair of the Krushangi Patel
GPH. University of Missouri-Kansas City School
of Medicine, Class of 2012
Paul Cheung
University of Colorado School of Medicine,
Class of 2013
Nneoma Nwachuku
University of Connecticut School of
Medicine, Class of 2013
Mitchell Li
University of Massachusetts School of Med-
icine, Class of 2013
John Luiza
University of Pittsburgh School of
Medicine, Class of 2013