on the cover >>>

Diabetes prevention poster for Cambodian immigrants in Connecticut. More information can be found on our cover story.

Newsletter of Committee on Global Public Health Medical Student Section of the American Medical Association

in this issue >>>
Metta, Karuna, Mudita, Uppekha: My internship 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

takes into account the special needs of the Cambodian refugee patients. They lived through a genocide, have traumatic brain injuries, have increased rates of many chronic diseases, and speak another language so foreign to me that over a few weeks I only learned one phrase. They live by a code of morals that encompasses Metta(mercy), Karuna(compassion), Mudita (joy), Uppekha(looking close and staying calm). Story continued on last page.

winter 2010-2011

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 medical 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.

Publically Speaking, the newsletter, is a frequent periodical, sponsored by AMA-MSS Committee on Global and Public Health (GPH. Throughout this upcoming year, several medical students will be placing their ink to the paper – focusing on the health care needs and development of countries and regions around the globe. We aim to bring much needed attention to current health care issues within and beyond the American border.

The day I began my internship this summer I was welcomed with a home cooked meal of chicken curry soup covered with basil, limes, and bean sprouts. The entire office joined to eat together and then walk around the neighborhood together. This was a way of living their health promotion curriculum entitled Eat, Walk, Sleep. The organization was the Khmer Health Advocates (KHA), based out of West Hartford, Connecticut, and one of about 20 Khmer organizations in the US. The organization is headed by Theavny Kuoch, a petite Cambodian woman with a great vision of integrated care for all Cambodians. The organization has taken on the monumental task of creating and implementing a medical home for the 300-400,000 Cambodian refugees living in the US. This medical 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 informed care. This trauma informed care

interim 2010 >>>

Addressing Chronic Disease is Essential to Achieving Millennium Development Goals
Developing nations find themselves in double jeopardy - battling acute infectious diseases while remaining horribly unprepared to face the rising threats chronic disease such as cardiovascular disease, cancer, motor vehicle accidents, and far-too-long ignored - mental illness. Large-scale diseasecentric 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).
Second-year University of Connecticut medical student, Katherine Wonneberger, at maternaland-child health facility in Haiti. Her summer research project, “The Effects of Migration on Women’s Breastfeeding Behavior,” earned her the Arnold P. Gold Foundation Student Summer Research Fellowship.

The eight Millennium Development Goals are targets set by member states of the United 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 charter. 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 Millennium Development Goals (MDGs) in individual countries. It is important to note that while the MDGs addresses diseases such as HIV and tuberculosis, NCDs remain glaringly 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 economic growth in developing countries). Continued neglect of NCDs in low to middle income countries stands to impede any future progress towards achieving the MDGs. In fact, consider NCDs as the latest addition to the category of Neglected Tropical Diseases (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 Connecticut 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 positive--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 Disease 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 transmission 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 identification 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 diminished access to healthcare, testing, and counseling opportunities. Second, targeted testing misses the mark. By categorizing ―high-risk‖ people, we fuel stigma associated with HIV testing and create barriers to testing. People are also likely to lie about (or even misperceive) their risk factors. 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 prenatal 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, as many people don’t want record of their participation or results. Finally, fear still consumes people when it comes to HIV testing. Despite education efforts, misconceptions still hold that an HIV case today is the same death sentence it was back when it first emerged in the 1980s. The list of barriers goes on, but an effective way to stomp out these embers is to offer HIV tests more universally through an opt-out process. In addressing lack of access to healthcare services, the CDC actually issued recommendations in 2006 to offer universal rapid testing and counseling in the Emergency Room (ER). This is often the only point-of-care for many marginalized patient populations, plus many early-stage and late-stage cases manifest themselves in this environment. The ER, however, is only a start. In the doctor’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. By implementing these recommendations through universal opt-out testing in all appropriate healthcare environments, we avoid glossing over unsuspecting infected individuals and increase the frequency and normalcy of testing. More importantly, we reduce stigma associated with HIV testing, dialogue, and status disclosure. Coupled with increased testing, it is equally important to scale up current education and prevention efforts. I was surprised to learn that a number of my youngest adult patients (statistically, the highest risk group) really did not know much about HIV. Patients should be made aware of the benefits of testing, 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 subsequently receives appropriate medication.

Fabulous Find
Updated every three years, the 82-page Pharmacological treatment of mental disorders in primary health care manual provides the clinician with evidenced-based information for the administration of pharmacological treatment to people with mental disorders in low-tomiddle income families. Resource is published by the World Health Organization and both English and Spanish versions of the booklet can be found at: http://www.who.int/mental_health/manage ment/psychotropic/en/index.html

These are facts that all individuals should know. With early diagnosis and access to care and services, HIV has become a much more manageable chronic disease with infected people living very normal and healthy lives for years. However, adequate knowledge and empowerment through education and testing are critical to prolong the quality of life of infected persons and reduce infection rates.
M.Ricks is a current Masters degree candidate at the Harvard School of Public Health. Prior to matriculation, she served as a research assistant in the Emergency Department of a major Boston hospital, testing and counseling hundreds of patients.

*Name has been changed.

who are we?
The AMA-MSS FindingcurrentCommitteeand Global public healthFor (GPH) is responsible forstuAn Agent on global and Public Health You That’s Right issues and educating medical reviewing domestic 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.

Write for Us
Have an interesting article, experience or picture to share? We are currently looking for public health related articles for our next issue, written for and by medical students. To submit, please contact newsletter editor: Nneoma Nwachuku nnwachuku@student.uchc.edu

(Metta, Karuna, Mudita, Uppekha, continued 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 adherence 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 Hartford or Danbury and were done by the resident 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 increased issues with adherence which may be rooted in underlying cognitive deficits, secondary to mental health issues. Often Cambodian patients need medication instructions repeated to them on numerous visits and often even this is ineffective. In one household in an attempt to get a woman to regularly check her blood sugar we placed a pictorial 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.

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 grandmother, who survived Pol Pot, and lived with 11 of her family members in Seattle went on a shooting spree and after killing her son-in-law and numerous grandchildren, shot herself. During the tragedy she never recognized her actions but instead was convinced that an external being was completing the shootings. The tragedy is augmented by the fact that she was diagnosed as schizophrenic. Stories like this where the tragedy is rooted in the history of trauma are especially trying for the Khmer population. In order to decrease the incidence of these events we must educate providers on the special needs of this population.
Prior to medical school, Lisa DiFedele received her MPH from Yale in Epidemiology of Microbial Disease. She has worked in public health infectious disease research and was able to travel extensively in Latin America and in Africa. She is an active member of UCONN’s Urban Service Track which produces future healthcare providers sensitive to needs of vulnerable populations She is involved in the AMA and Connecticut State Medical Society. She is former co-chair of the GPH.

about us >>>

Meet the 2010-2011 GPH Committee
David Dornbos

Wayne State University, Class of 2012 Chair Andrew Osten Tufts University School of Medicine, Class of 2012 Vice Chair Andrew Bucholz UMDNJ School of Osteopathic Medicine, Class of 2013 Olutoyin (Toyin) Okanlawon Vanderbilt School of Medicine, Class of 2011 Krushangi Patel 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 Medicine, Class of 2013 John Luiza University of Pittsburgh School of Medicine, Class of 2013