Morning Consult | August 22, 2014

By Bill Frist

I remember a time in South Sudan when I was on a surgical mission trip. The shaman of a local tribe brought us a young man who was dying. The local healers had tried everything – medicines, rituals, prayers. But the one thing this man needed was forbidden in their culture. He had a deep abscess on his inner thigh in desperate need of draining. He was clearly in septic shock from bacteria in his blood from the wound as well. But in his culture, you could not puncture the body in anyway. It was considered desecration of the body.

However, he was dying. Because I was serving with a group of established medical aid officers, our methods—though foreign—were proven. The shaman and the young man were terrified, but they were also desperate.

I took my scalpel, wrapped my hand respectfully around the shaman’s hand, and together we incised the deep abscess.

The young man immediately felt better and the infection was cured with further surgery and antibiotics. He fully recovered and the shaman eventually thanked me. He was skeptical and fearful at first, but the patient lived, and the shaman was convinced to trust me.

In dealing with the largest Ebola outbreak in history we face many challenges: the rapidly fatal course of the illness and the advanced medical supportive care required for survival. We have seen that with the case of Dr. Kent Brantley, who was recently discharged from Emory University Hospital. While he did receive an experimental drug and a blood transfusion from an ebola survivor, there is no scientific way to determine if that had any impact on his course of illness. What we do know is he did well because he was contained quickly and had a known course of supportive care. The unfortunate fact is that we have no evidence that any amount of American medical resources or new experimental drugs will end the outbreak on its own.

The only solution is prevention, which relies on containment and isolation. The sick must be rapidly identified and contained. Their contacts must be followed for 21 days so they can be rapidly isolated, should they develop symptoms. Their care must be delivered in the a hazmat suit. If the patient dies, and 70% do, the body must be properly disposed of because a recently deceased Ebola victim is actively shedding the virus from his skin.

On August 7th we heard compelling testimony from Dr. Ken Isaacs, Vice President of International Programs and Government Relations at Samaritan’s Purse about the cultural barriers to containment. He testified before the House Committee on Foreign Affairs and related his recent experience.

Containing the Ebola outbreak requires not only the right medical tools, but a sensitive understanding of the culture in which it is flourishing.

Contributing to Ebola’s virulence are the cultural traditions around the veneration of the dead. Dr. Isaacs mentioned this in his testimony, and I later discussed this practice with the Center for Disease Control. They explained the local ritual further:

A deceased community member’s body is rinsed, wrapped in clean cloth and rolled in a mat of palm tree branches. A coffin is used if the family can afford it. The body is then buried in a community cemetery and the burial cloth may be kept as a memento of the deceased. During the process mourners will kiss and touch the body repeatedly.

These traditions are an important part of community and family mourning. But they can also be deadly to those in close contact with an infected body. Dr. Isaacs testified his staff had been threatened with violence when they attempted to collect bodies for sanitized burial.

Further testimony revealed that there has even been doubt about the virus’ existence among the local medical community. Dr. Isaacs told the story of a well-respected and educated Liberian physician who visited the facility in Monrovia and examined patients without protective gear, mocking the existence of the virus to his colleagues. He passed away in Nigeria a week later.

Certain groups have even assaulted containment centers with looting and violence. Why? The incident in West Point Liberia was driven by both fear of having a containment center in their community as well as a complete disbelief that the virus is real – total confusion begetting total chaos.

The United States has a role to play here, but we must move forward carefully.

Starting in 2003 with PEPFAR, the President’s Emergency Program for AIDS Relief, healthcare as a mechanism of diplomacy has become a more prominent part of our foreign policy. However, foreign policy is a dance, a negotiation of shared goals and identification of conflicts between nations. Even when the goal seems clear – to stop an Ebola outbreak for example – there is always an inherent tension between cultures, a worry about ulterior motives, a distrust of the unknown and sometimes a memory of the U.S.’s past use of health initiatives as cover for military operations.

But distrust and the cultural barriers can be overcome, as I saw with the young patient in South Sudan. While that was a single incident and this is an outbreak, the underlying principles are the same: We have to be physically present. We have to prove that our strange customs and beliefs can save lives. It’s an extension of what doctors have always tried to do with scared and vulnerable patients—be at the bedside, listen, and heal.

Ebola is more rapidly fatal than HIV, and has no specific treatment. But like HIV, it is a viral illness, spread through close contact that is often exacerbated by cultural beliefs and practices. PEPFAR was successful in reducing AIDs related mortality by 33% from 2005 to 2012 and it was the result of a coordinated and targeted effort to provide treatment as well as education. It required “boots on the ground” to integrate with the culture and build trust.

Today West Africa is facing a devastating illness in a culture of distrust and mis-education. The rest of the world is working in the face of budgetary constraints and fear of personal exposure. Add in the poor press about experimental drugs with access limited to Americans, and the fog of suspicion thickens. While USAID has already committed $14.55 million in emergency funding, this money has not bought the needed trained professionals and supplies to accomplish containment. A recent Kaiser Family Foundation report noted only $13 million of the $46 million needed in Liberia and Sierra Leone has been received.

This is a time for the United States—government, NGOs and all—to seize the mantle of global health as a vital diplomatic instrument to strengthen confidence in America’s intent and motives. Everything we do on the global stage sends a message. This is an opportunity for the U.S. to be a global leader, build trust, and show that we can break down cultural and communication barriers and align for a common goal. But to do this we need to go to West Africa with sensitivity as well as knowledge, and it needs to be a priority because it is the only way to stop the outbreak.

For some, this is a terrifying proposition, but so is the devastation of the population if Ebola is not adequately contained. We have the resources to safely fight the virus. We understand transmission and containment. But putting that knowledge to work in West Africa means putting trained and funded intervention where it’s needed most: at the bedside.

The Mother and Child Project:
Helping Families in the Developing World
Keynote Speaker: Former US Senate Majority Leader Bill Frist, MD
Host: Senior Pastor Mike Glenn
This faith-based conference will host dynamic speakers talking about the critical global health issues of maternal and child health, with a special emphasis on the benefits of healthy timing and spacing of pregnancies as a life-saving mechanism in the developing world. Local and national speakers will come together to talk about their special work as service providers in countries around the world, caring for mothers and children worldwide. We will lead a robust Q&A session with all the speakers encouraging further discussion. And the conference will close with practical, simple steps for how YOU can save lies and help families thrive in the developing world. 
Wednesday, September 24, 2014
8:30-2:30 pm, Brentwood Baptist Church
7777 Concord Road, Brentwood, TN 37027
Breakfast and Lunch included
Speakers
Gary Darmstadt, MD,  Bill & Melinda Gates Foundation
Tom Walsh,  Bill & Melinda Gates Foundation
James Nardella, Lwala Community Alliance
David Vanderpool, MD, Live Beyond
Lisa Bos, World Vision
Rick Carter & Terry Laura, Compassion International
Lucas Koach, Food for the Hungry
Jenny Eaton Dyer, PhD, Hope Through Healing Hands
John Thomas, Living Hope
Questions?
JCrain@HopeThroughHealingHands.org
This conference is free and open to the public. Advance Registration is requested by Thursday, September 18.

Originally published by the New York Times

Matt Cone writes about teaching students about global issues in the classroom, with a special nod toward Senator Bill Frist. Cone is a teacher at Carrboro High School in North Carolina.

Of the more than 8,000 class periods that I have taught, one stands out as my favorite — not only for what happened in the class but also for how it transformed my teaching. The class took place in the fall of 2004 and what strikes me about it now is how primitive it was by today’s technological standards. Indeed, the entire class consisted of the students sitting in a circle, staring at a speakerphone, and engaging in a dialogue about global health with a guest on the other end of the line. Fortunately for us, the guest was Dr. Paul Farmer, a path-breaking physician who co-founded the organization Partners in Health and who is the subject of a book the class had read, “Mountains Beyond Mountains.” For forty minutes, the students peppered Farmer with questions about Haiti, about how to best use one’s talents to address global health issues, and about how he had worked with Republicans and Democrats to ramp up global health funding.

As soon as we hung up, it was immediately apparent that the talk had lit a fire under the students: they not only wanted to track down the books and films that Farmer had referenced, but they also wanted to form a global health club. I returned home that night and told my wife, “I need to find a way to do this more often.” Over the past ten years, I have pursued having students study complex global issues in depth and then engage in discussions with a range of experts. The good news is that teaching about global issues through the use of technology and expert speakers is far easier than one might expect, it has great appeal for teenagers, and it frequently leads to learning that extends far beyond the classroom.

Thanks to the Internet, exposing students to global issues and to experts who work on them has never been easier. When I started my career, finding articles and videos on international issues was an arduous process that required hours of sleuthing and juggling VCR tapes; today it is possible with just a single computer to find and within minutes share information about even the most underreported international news stories. So, for example, if my class wanted to know more about the recent Ebola outbreak in West Africa, we could accomplish the following within a single period: find articles about it online, locate websites to track the disease’s spread, set up Google Alerts to keep us abreast of the latest news, and reach out to experts in public health, journalism, history and government who could help us to understand the issue in greater depth. Since staging a dialogue with Paul Farmer a decade ago, we have been fortunate to arrange dozens of meetings or Skype calls with a wide range of experts that includes Muhammad Yunus, Jim Yong Kim, Laura Bush, Colin Powell, Jeffrey Sachs, Noam Chomsky, Bill Frist, Dan Ariely, Paul Collier, Alan Mulally, Christy Turlington, Adam Hochschild, Peter Singer and many more.

Learning about global issues through the use of technology and expert speakers appeals to teenagers for two reasons. First, it’s not “busy work.” When students know that they are reading chapters from a macroeconomics text so that they can prepare for a wide-ranging dialogue with Jeffrey Sachs, they are eager to prepare as thoroughly as possible. Students appreciate that when they speak with an expert, they are able to ask critical questions and engage in an intellectual give-and-take with someone who (usually) treats their questions and opinions with respect. In fact, this goal of critically examining the issues and approaches that we are studying is one that is modeled by the experts with whom we speak. So, for example, my students spoke with Sachs and heard his ideas about why foreign aid can provide the big push that lifts nations out of poverty, and we also spoke with one of Sachs’ most vocal critics, Nina Munk, whose book “The Idealist” maintains that much of Sachs’ efforts have failed. Similarly, my students met with World Bank President Jim Yong Kim on the same ...

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One of the best things about healthcare delivery in Guyana is that it is nationalized.  Care is free and available to every citizen.  It is financed and managed through the Ministry of Health working together with regional and local government. There is an independent private sector.   However, despite a national health system, there are several gaps in the delivery of health care in Guyana.

Chronic diseases, such are hypertension, diabetes and heart disease, are becoming more prevalent in Guyana and currently there is not an infrastructure in place to help manage this growing problem.  Patients are presenting to the emergency department at advanced stages at which time there may not be great treatment options available.    Unfortunately the regional health center, which would ideally be the place for primary care, is not very equipped. There is usually just one physician available to staff a large local population and he/she may not be well trained to manage chronic disease.  The availability of equipment such as blood pressure cuffs, glucometers, monofilaments, debridement tools for diabetic ulcers are often in limited supply. Lab testing and monitoring are usually not available.  The idea of routine screening and preventative medicine is nonexistent.  Ancillary staff, if available, is also not well trained. 

While most patients living along the coast have access to some sort of health care, whether through regional health centers or the local emergency department, those who live in the interior have little to no access.  This is largely because of the sparse population and difficult terrain. The population comprises mostly of indigenous people and miners - in emergency situations, they travel for days to the capital to receive care.

In Guyana, there is very little support for persons with mental health disorders or substance abuse.  During my short time in Guyana, there were more than a handful of persons presenting with suicide attempt, often with paraquat, a freely available but deadly herbicide.  At a public health level, there needs to be better regulation of who has access to these poisons as this is an easily preventable cause of morbidity and mortality.   There is poor education about mental illness among the population as well as among providers.  If a patient survives a suicide attempt, he/she is discharged from the hospital without any resources or treatment to address with underlying mental illness.  Substance abuse, specifically alcohol, is never addressed.  Training providers as well as the development of a psychiatric unit or treatment center will be a small step to help address this growing problem. 

One of the largest challenges to health care delivery in Guyana is the lack of an integrated health information system.  Medical records are completely on paper and patients’ charts do not go with them throughout their contact with the medical field.  The medical record is not used to support decision making.  For example, if a patient presents to the ED with hypertensive emergency, a new chart is made up for the admission.  Even though the same patient presented a week prior with the same issue, the record is not automatically included and there is no way to use information about their previous treatment to guide treatment decisions now.  In addition, the contents that make up the medical record are sometimes sporadic and often incomplete.

There are many areas that need to be built up for the health care system in Guyana to become what it needs to be.  There needs to be programs in place for advance training of physicians and compensation and work plans that keep these well trained physicians interested in staying in Guyana. Local health centers need to become the first line for screening and management of chronic diseases.  Also, within the public health sector education programs need to be developed that teaches local population about disease, mental illness and a healthy lifestyle.

In Guyana, there appears to be a commitment by the government to improve the overall healthcare delivery system.  With the monetary support and partnership with many foreign agencies, Guyana is slowly on its way to delivering the care its people need.

 

All I can say is, I don’t know how they do it. I have finished my time in A&E and have been on female medical ward for the last week and a half. The female medical ward is housed in a new facility that opened several months ago. There are approximately 8 patients per room.  Patients have to bring their own sheets, clothes, toilet paper, water, and any other supplies that they might need.   There are many nurses and even more nursing students around, but I have yet to figure out exactly what they do.  Care by the nursing staff is haphazard at best.

It is so busy here!  There are two interns who take care of 60-80 patients at any given time and every 3rd day they do a 36 hour shift.  Rounds every morning are quite exhausting and interminable.  We either help the interns pre-round (this may involve checking vitals, starting IVs, updating orders) or we round with the sole internal medicine consultant (in the country!) during bedside teaching rounds.   There are about 20 medical students who attend these rounds and it is the only semi-structured teaching they receive during their internal medicine rotation. I spent some time going over a few cases with them and though they are eager and enthusiastic to learn medicine I worry about how they will develop the skill sets needed to identify and manage disease processes.

Unfortunately, because the wards are so busy and it is often only the interns around to manage patients, many things are missed or overlooked.  Labs take a long time to return and once they do show up may be forgotten until the next day on rounds.  A patient’s clinical status may deteriorate without anyone recognizing or alerting a physician of the change for hours.   There is a lot of death and, unfortunately, sometimes it seems all but inevitable. 

Despite all the obstacles present, the best part about being here is the patients I get to work with.  There is such a sense of gratitude and appreciation for the care that they receive and readily acceptance and trust even when things do not go quite right.  There is such strength and resilience in the human spirit.

Yesterday was the last day of the rotation and I spent part of the day in medical records going over a couple charts of patients that I had heard about or taken care of.   As I sat on the hard wooden bench, in the cloying sticky heat waiting for them to pull the records, I looked around and saw the tall shelves of recorded births and deaths at GPHC for the last 50 years.  It was particularly striking to me at that moment that somewhere amidst all of that paper, the record of my birth could be found.  Looking at GPHC currently, it is hard to imagine what it must have been like so many years ago.  Nonetheless, I feel like I have come full circle and I never could have predicted it.  I am grateful for the opportunity to be here and I look forward to creating opportunities to come back to teach, work and help build up the healthcare of Guyana.

Published at ForeignPolicy.com on August 4, 2014

The news coverage of the Ebola outbreak in West Africa has left Americans reasonably unsure whether the threat is real or hype. In fact, it is both. The outbreak's startling spread and high mortality rate is indeed a real crisis, but it is unlikely to pose a serious threat to Americans at home. Stark differences in natural, cultural, and capacity factors between West Africa and the United States, and the way the virus is transmitted among humans make it extremely unlikely that the United States will face the kind of crisis that has swept through Guinea, Sierra Leone, and Liberia.

The low likelihood of a serious threat to us from Ebola, however, does not mean we should be unconcerned. Though the story is becoming part of a hype-and-fizzle news cycle that contributes to dangerous complacency and even cynicism about the very real threat of a global pandemic, such as from H5N1 influenza ("bird flu" or "avian flu") that could mutate and become readily transmissible among humans, it still carries important lessons.

Like bird flu, Ebola is an animal virus whose novelty among humans makes it highly pathogenic. But Ebola is spread only through direct contact with body fluids of an infected person, and a person directly exposed to Ebola is not contagious if he or she shows no symptoms, which makes travel possible and screening and response relatively straightforward, if admittedly challenging, for competent authorities.

By contrast, a traveler infected with a mutated bird flu could be asymptomatic yet contagious for days, giving no indication of the acute public-health threat they represent and rendering global point-of-entry-focused security measures dangerously ineffective. This scenario is the most common one discussed regarding a potential global pandemic -- it's not far-fetched and should be added to the growing list of things that keep a president up at night.

For its part, the Obama administration has responded to Ebola appropriately thus far, and has not treated the situation as a crisis it shouldn't waste. That said, a bit of "good crisis" thinking is perhaps in order to improve our ability to prepare for and respond to a future pandemic threat. Instead of allowing the "lessons learned" process around Ebola . . .

read the rest of this article at ForeignPolicy.com

This articile originally appeared at Tennessee Christian News.

A Tennessee nonprofit with big-name ties is trying to make a difference throughout the developing world.

Nashville-based Hope Through Healing Hands promotes quality of life through a variety of ways, including emergency relief and addressing such health issues as HIV and clean water, Dr. Jennifer E. Dyer, executive director, told the Tennessee Christian News. Former U.S. Sen. Bill Frist is chairman and founder.

Its flagship initiative, she said, is the Frist Global Health Leaders Program. That initiative offers modest grants to universities and medical centers for graduate level students and residents in the health professions to do service and training around the world.

The group’s website is hopethroughhealinghands.org.

Now, Hope Through Healing Hands is partnering with The Bill & Melinda Gates Foundation to emphasize birth control. That effort is called The Faith-based Coalition for Healthy Mothers & Children.

The coalition aims to gather support among faith leaders across the United States on the issues of maternal, newborn and child health in developing countries, according to a press release. The coalition will place a particular emphasis on the benefits of healthy timing and spacing of pregnancies, including access to a range of contraceptive options, in alignment with its members’ unifying values and religious beliefs.

On July 14, the coalition sponsored a panel discussion at Belmont University in Nashville. Frist and Melinda Gates led the discussion, titled, “The Mother & Child Project: Simple Steps to Saving Lives in the Developing World.” U.S. Olympic figure skating champion Scott Hamilton, who with his wife Tracie is an active global health advocate, moderated the event. More than 250 individuals representing the faith community, global health NGO and higher-education sectors throughout greater Nashville attended the discussion to learn how they can get involved in the issue.

Frist said, “Contraception is a pro-life cause,” according to the press release. He added, “…if you delay first pregnancy to 18 years old, you can increase survival in countries where 1 in 39 women die in childbirth, and cut the chance of children dying by 30 percent, enabling them to stay in school and become productive members of families.”

Dyer said the partnership with Gates will continue for at least the next year and a half through a grant, although she hopes to extend the grant beyond that period.

Endorsements for the coalition include actress Kimberly Williams Paisley; musicians Jennifer Nettles, Amy Grant and Michael W. Smith; Jena Lee Nardella of Blood:Water Mission; Pastor Mike Glenn of Brentwood Baptist Church; Pastor Rick White of The People’s Church; Bishop T.D. Jakes of The Potter’s House; and Elizabeth Styffe of Saddleback Church, among others.

As the CDC treats the nation’s first two Ebola cases there are a lot of questions and concerns about the disease in America—Could it become an epidemic here? How contagious is it? How is it caught?

Although my medical specialty is cardiothoracic surgery, I have spent a good deal of time working on global health issues in Africa and elsewhere, and I have been in close contact with the CDC over the past week. I thought it might be useful to highlight some of the features of Ebola that make it more—and less—dangerous.

As a viral disease, Ebola follows a fairly predictable timeline.

Incubation: the time between when a person is exposed to the virus, and when symptoms start. In Ebola, that incubation period can be between 2 and about 21 days. During that time, the patient does not feel sick and research suggests that they are not contagious. (see doi:  10.1016/j.phrp.2011.04.001) There’s been concern about infected travelers spreading Ebola to other parts of the world after traveling from West Africa. That is certainly possible with a long incubation period.

Onset of Symptoms: However, once an infected person starts to feel sick, they are quickly seriously ill. There is sudden onset of fever, intense weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash, impaired kidney and liver function.

Unlike a cold, when you could be spreading the virus and not really feel that unwell, Ebola patients know that they are sick. This is actually a good thing, because sick patients are easy to identify, isolate, and treat. Other diseases still need to be ruled out—malaria, typhoid fever, cholera—but it’s clear that the patient has a severe illness.

Transmission: Here is perhaps the scariest part. How do you get it? How did Dr. Brantly get it? How is the virus spreading between people?

Some diseases are infectious, but not contagious. Lyme Disease or Rocky Mountain Spotted Fever are transmitted from ticks to humans but cannot be spread from human to human.

Contagious diseases can be spread from person to person, but not all equally well. Chicken pox, small pox, and measles, for example, are airborne spread—meaning the virus spreads very well with each exhale. These diseases are highly contagious.

Ebola, on the other hand, is only spread through direct contact with the bodily fluids of infected patients—blood, semen, sweat, urine and other secretions. And then, that fluid needs an easy entry into the body: a shared needle, an open cut, an exposed mucous membrane. It could possibly be spread through a cough or a sneeze, but that would require a fairly large drop of mucous to be coughed into another person’s face and get into their mouth or nose or eye.

For healthcare workers in West Africa, this could be possible. With limited supplies, perhaps there is a tear in a glove, or there aren’t enough goggles to go around, or bedding is reused because there isn’t an adequate way to clean it.

If patients are being cared for at home—either because they are too far away from a medical facility, or there’s some cultural distrust of foreign aid workers—caregivers in close physical contact with sick loved ones would have no medical or cleaning supplies. There are also vast cultural issues that influence the virus’ spread, and I’ll touch on those soon.

But with supplies, knowledge, and fully-equipped medical centers, these circumstances would be much less likely to happen. For these reasons, the Centers for Disease Control (CDC) is not concerned about an outbreak in the United States.

The situation is certainly serious—and will continue to be very serious in West Africa. But although we don’t know everything about how this virus behaves and changes, we do have quite a bit of useful knowledge about how to keep it contained, and how to keep our healthcare workers at home and abroad safe.

It is good to be back in Guyana.  It has been a week since my arrival and there is a feeling of returning home.  Although I left this country when I was very young, the culture, the food, the sayings, even the hot humid climate and cooling ocean breeze are all so familiar and welcomed.

Nadine Harris

I have been working in A&E at Georgetown Public Hospital, the country’s tertiary care center, for the last 5 days.  I am amazed at the broad spectrum of pathology that we see in any given day - some of these have included cerebral malaria, snake bites, herbicide poisoning, tetanus, advanced HIV, acute myocardial infarction, infected diabetic foot ulcers, and strokes.  What is most impressive to me is how many complications I have seen from poorly controlled chronic medical conditions, many of the same disease processes that we deal with in the US.  As an internal medicine resident, I think about my own panel of patients back home and how aggressively we are taught

to manage diseases such as hypertension, diabetes, and coronary disease.  Unfortunately, this is not possible in Guyana in large part due to lack of a trained physicians to take care of these people and poor medical records (surprisingly, many of the first line drugs that we use to manage chronic illness are available here).  Guyana, like so many developing countries, continues to struggle with “brain drain” as more and more trained professionals migrate in search of a more economically secure way of life.  In the medical profession, those who are left behind do the best they can, but are often overworked and undertrained. 

Working in a developing country with so limited resources certainly requires that I adjust the way I think about and approach a disease process; this is easier said than done.  The emergency medicine residents do the best that they 

can to be aggressive in the resuscitation of very sick patients - unfortunately, often with so few ICU beds, ventilators, equipment for monitoring, it is difficult to sustain a high level of care for the critically ill and many do not survive.

There is just so much that we take for granted in the U.S.  I met a 17 year old girl who was brought in to A&E by her parents with 6 months of a progressive motor weakness and spasms that left her wheelchair bound and in sign

ificant pain.  She had been in and out of the hospital, with essentially negative work up including lumbar puncture, plain films and CT head.  She had seen a private neurologist and needed a MRI.  Due to the cost she has not yet gotten the test and even with her consultant advocating her case to the ministry of health, the outcome is still pending.  Getting such a simple test that is so easily accessible to us in the U.S. seems an almost insurmountable hurdle to overcome in the work up of her disease.

It is humbling experience to be here and is a great reminder of what a privilege it is to be able to practice medicine and to serve those who need the most help.  I am constantly being reminded to how much I don’t know and how much I can learn from my patients.

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