Wally Carlo in Zambia with a birth attendant (front row center) he helped train, surrounded by more than a dozen children she has delivered safely over the years.UAB Professor of Pediatrics Wally A. Carlo, M.D., doesn’t need a research paper to prove the value of the School of Medicine’s global health initiatives. All he has to do is look at a single photo.
In the photo, Carlo is standing in a Zambian village surrounded by a young woman and 13 children. The woman, a birth attendant whom Carlo and UAB faculty and students helped instruct through a newborn care training program, delivered all the children in the photo.
In a country with infant mortality rates as high as 25 percent just 15 years ago, this picture is worth a thousand words to Carlo. “We know we can save lives with this program,” Carlo says. “When we started this work in Zambia in 2000, one out of four kids would die in the first year. Now it’s down to about one in 15. If this program were implemented worldwide, it could save one million babies each year.”
UAB has been involved in these types of global health initiatives for decades, but last year the School of Medicine formalized its commitment to such programs by naming Michael S. Saag, M.D., the Jim Straley Endowed Chair
in AIDS Research and director of the UAB Center for AIDS Research, to a new position as associate dean of global health. In this role, Saag and Rubin Pillay, M.D., Ph.D., assistant dean for global health innovation, are helping coordinate UAB’s established global health partnerships, and also developing new international research and service learning opportunities.
“The tendency among Americans is to only think about the expertise we have to offer other countries, but other places have lessons to offer us as well,” Saag says. “Areas of Alabama suffer from some of the same health challenges that we see in the developing world. Strategies we develop internationally can be implemented here to improve the health of our fellow Alabamians, and vice versa. The whole trick to successful global health programs is to make sure that they’re bi-directional, both in terms of exchange of students but also in terms of critical exchange of ideas.”
Strategic Expansion
“We have been engaged almost since our inception as a university with international programs,” Saag says. “But these programs were developed almost organically on their own by individual faculty members who have a connection to a certain country. There were well over 50 programs going on at one time, but it was not a strategically developed effort.
“What we want to do is create a coordinated, more efficient operation in international health,” he adds. “We’re looking at each program in terms of its research grant potential, philanthropic potential, training opportunities, and the ability to provide service. We want to identify the areas where we’re particularly strong and make them even stronger, and identify new areas where we need to invest more resources.”
Global Health Michael Saag and Assistant Dean for Global Health Innovation Rubin Pillay are leading the school’s efforts to enhance and expand its global health programs.In this case, “resources” does not necessarily mean money. Saag says one of the primary goals of the School of Medicine moving forward is to get more UAB faculty, students, and residents and fellows involved in the School’s global health initiatives. “We’re looking at where we might invest human capital as well as dollars. We want faculty to be able to produce something that is long-lasting, be it a research paper or a new finding that enhances clinical care. And, of course, we want them to be rewarded with their own personal growth and experience.”
Carlo’s work is a prime example of what these initiatives can accomplish. Instead of merely providing medical services to people, Carlo and his team have trained health care workers in various countries—including Guatemala, Kenya, Congo, Pakistan, and India—on how to offer these services themselves, so the improvements in care can continue long after the team has returned to UAB.
“Our focus is on developing these educational programs and then teaching what we call master trainers—physicians, nurses, midwives, and birth attendants—how to take care of the pregnant mother and the baby after birth,” Carlo says. “These programs that we developed first for Zambia have been shown to reduce mortality markedly, and now they are being implemented by the World Health Organization and other groups.”
German Henostroza, M.D., associate professor in the Division of Infectious Diseases, also is working in Zambia with the country’s Center for Infectious Disease Research to develop programs to screen for such diseases as tuberculosis, HIV, and cervical cancer. He says the School of Medicine is in the process of expanding these initiatives to Panama and Peru.
“There is great momentum at UAB right now in terms of the recognizing the importance of global health,” Henostroza says. “All the leadership at UAB is heavily involved and excited about expanding the global health component. The reason we need this is because whatever happens overseas can reflect back here at home. It gives our residents, students, physicians, and faculty the opportunity to gain experience with various diseases in different areas of the world, and that understanding is important to their ability to provide care here in the U.S. and in Alabama.”
A Legacy of Care
Alan T.N. Tita, M.D., M.P.H., Ph.D., a native of Cameroon and professor in the Department of Obstetrics and Gynecology, is intimately familiar with the health care needs of that country. Tita received medical training there before coming to UAB, and in 2010 he began a collaboration that is now known as the Cameroon Health Initiative at UAB.
“It started with us sending UAB residents there to do their clinical electives,” Tita says. “Now it has expanded to include residents from other U.S. OBGYN programs. We’re also partnering with major health agencies in Cameroon, including the Ministry of Health and major universities, in research and service programs. In addition, we are working with a large health organization called Cameroon Baptist Convention Health Services, which has seven major hospitals and more than 80 health clinics. It provides comprehensive facilities and leadership in the prevention of mother-to-child transmission of HIV, with funding from PEPFAR (U.S. President's Emergency Plan for AIDS Relief).”
Alan Tita leads the Cameroon Health Initiative, which has expanded OBGYN and infectious disease partnerships across his native Cameroon.One of the program’s current projects is a partnership with the Cameroon community in Birmingham to promote Hepatitis B vaccines immediately at birth for babies born to women who have the disease. Jodie Dionne-Odom, M.D., assistant professor in the Division of Infectious Diseases, says approximately 10 percent of people in Cameroon have Hepatitis B, and babies who are not vaccinated at birth run a greater risk of developing cirrhosis and liver cancer later in life.
“This can help prevent a disease that can be hard to treat, and prevention is the way to move forward on a country-wide level,” Dionne-Odom says. “We know that vaccination at birth is an effective way to prevent transmission to the baby.”
Education is key to many of these initiatives. Having a qualified physician provide direct medical care can be tremendously valuable in countries lacking in quality health care providers and facilities. But specifically because of that lack of expertise, it is equally important to provide medical training to locals.
This is especially true when it comes to emergency care, which is why Scott Irvine, M.D., M.P.H., FACEP, assistant professor in the Department of Emergency Medicine, began the International Emergency Medicine Fellowship in 2012. The fellowship has established training sites in several countries—with a focus on Kenya, Cambodia, Panama, and Peru—where UAB fellows both provide care and teach locals about various emergency treatments.
“There is a myriad of different avenues to pursue global health,” Irvine says. “The International Emergency Medicine Fellowship is focused on education. We have specialty training here at UAB that is not available overseas, so we work with our counterparts in tropical medicine and emergency medicine and provide them with training that they can’t receive in-country. We also provide direct care where we can, because there is definitely a lack of physician-level providers in some of these places. But we can’t always be there. What we can do is leave them with education, which will help improve care for the long-term.”
Irvine says Kenya, for example, has only one board-certified emergency physician in the entire country. As a result, the majority of emergency care is provided by people who have limited training in the field. The International Emergency Medicine Fellowship, which has already produced two fellows and will produce three more by the end of 2016, is working to address that need.
“We are focused on the development of emergency medicine as a specialty globally,” Irvine says. “We’re working at a hospital in Kenya where we’re training clinical officers, which is the equivalent of a nurse practitioner or physician assistant. We’re expanding clinical officer training in emergency medicine and critical care at two hospitals.
Dr. Browning Wayman, current International Emergency Medicine fellow, walks with children to clinic in The Gambia.“We also do disaster relief and primary care in areas where there are no physicians. We’ll go to a small, remote village and provide care for patients who can’t get it anywhere else. We were in Nepal recently doing disaster response, and while there we were also providing education to improve their ability to take care of patients on their own.”
Irvine was able to witness firsthand how this education can pay off. He says barely an hour after he had finished instructing a Nepalese health care worker on wound care, a women walked in with a severe laceration on her hand that had become so infected she was running a fever.
“I was able to walk him through the appropriate steps for wound care,” Irvine says. “When she came back the next day, the fever was gone and the infection was resolving. The teaching that we did changed his ability to care for everyone in his village, which in turn changes hundreds of lives. That’s one small example of how these initiatives make a difference globally.”
Having a global impact is what the School of Medicine hopes to accomplish with the increased emphasis on worldwide health initiatives. As last year’s Ebola scare proved, disease does not recognize national borders. “Part of medicine in the 21st century is you no longer can just focus on problems here in America,” Irvine says. “Global travel is more accessible than ever before, so to think that problems in the developing world will stay in the developing world is not realistic.
“This is a way for us as an institution to be part of the altruistic and humanistic side of medicine. We can sometimes miss out on that in the day-to-day rush at home. But when we are part of these global health initiatives, we’re kind of getting back to why we got into medicine in the first place.”
By Cary Estes