COURSE IMPRESSIONS | The Harvard GHP 298 Winter Session Trip brought ten masters and doctoral students of public health to India to examine the country’s framework for addressing non-communicable disease in partnership with the Public Health Foundation of India (PHFI). Students also learned about the broad array of community-based interventions targeting chronic conditions, primarily hypertension and diabetes, that PHFI and the UDAY Foundation have launched in recent years. After an initial briefing at PHFI’s headquarters in New Delhi, students visited program sites in Visakhapatnam (or Vizag) on the southeast coast and Sonipat to the north of the National Capital Region. Over a period of two weeks, trip participants engaged in a mix of rural and urban site visits around these areas. The following is an account of the 2017 Winter Session Trip, beginning with background information on the partner organization in India as well as the current burden of chronic disease in the country. The itinerary for the trip and the host organization programs are reviewed here, as well as suggestions for future moderations of both the Harvard course and the interventions utilized by PHFI and UDAY. Overview of PHFI The Public Health Foundation of India is a public-private initiative to improve the health of India. Launched by Prime Minister Dr. Manmohan Singh in 2006, PHFI is an independent foundation that aims to improve the country’s institutional capacity for public health. This takes the form of policy development and implementation nationwide, as well as research and training for clinicians and public health professionals. PHFI’s initiative to combat the rising burden of 1 chronic disease is an innovative large-scale community-based effort not seen elsewhere in the country’s health policy. The interventions seen by trip participants were unique in their goal of screening every individual in the catchment area. Despite this scale, PHFI is committed to building strong community ties. Partnerships with community leaders and intensive outreach programs, as well as an emphasis on hiring and training health workers from their home communities, have translated into a high degree of participation and community engagement in PHFI’s goals for improved health. Students were impressed with how effectively health workers were able to build a rapport with community members while managing a large screening caseload. Overview of Project UDAY India is experiencing a growing burden of noncommunicable diseases (NCDs), with NCDS accounting for 40% of all hospital visits and over 50% of all deaths.1 This growth is thought to be due to a number of factors including increased longevity, tobacco use, and urbanization leading to changing diets and decreased physical activity. The four most prevalent chronic diseases in India are cardiovascular diseases (CVDs), diabetes mellitus (DM), chronic obstructive pulmonary disease, and cancer. For example, there are currently 69 million people in India with DM, and this number is expected to increase to 124 million by 2030.1 As CVD and ​ DM risk can be modified by lifestyle changes and appropriate medical care, initiatives to address these diseases will be critical in stemming the rising burden. One example of such an initiative is PHFI’s Project UDAY. UDAY is a comprehensive diabetes and hypertension (HTN) prevention and management program currently being implemented in both Sonipat district, Haryana and Visakhapatnam district, Andhra Pradesh. UDAY first trained community health care workers to collect baseline health assessments of the total population 1 U​ padhyay, RP. An overview of the burden of non-communicable diseases in India. Iran J Public Health. 2012;41(3):1-8. Epub 2012 Mar 31. 2 (400,000). This helped calculate the current prevalence of DM and HTN in the two districts, as well as the prevalence of modifiable risk factors such as tobacco and alcohol use. Subsequently, UDAY has been screening adults (≥30 years) for DM and HTN and then referring high risk patients to the health system for appropriate diagnostics and treatment. UDAY workers follow up with these patients regularly to track compliance with medical referrals and determine barriers to treatment access. Follow-up visits for those in compliance with UDAY recommendations consist of medication regimen review and confirmation of patient comprehension of access points within the healthcare system, as well as blood pressure readings and finger stick glucose checks. Additionally, workers take advantage of the in-home aspect of screenings to provide health education and disseminate prevention messaging. UDAY has created a culturally sensitive education booklet for use in increasing the public’s awareness of HTN and DM risk factors. This tool is then used during regular follow-up visits to bolster a patient’s understanding of disease progression and key interventions. 3 Overview of Itinerary The trip orientation took place in October, during which time Dr. Cash provided a brief overview of the goals and plans for the course. Through a November dinner, students had the opportunity to meet fellow classmates and discuss certain aspects of Indian history and culture. Dr. Mohan of the Public Health Foundation of India was available on Harvard’s campus in November for a brief session with all participants to answer any questions. The course officially commenced on January 2 with a team meeting at PHFI headquarters in Gurgaon, where Dr. Mohan presented on PHFI’s work and provided an overview of chronic disease in India. PHFI had organized an overnight stay for students at the USI premises, a hotel located within a military base on the outskirts of New Delhi, and coordinated all transportation. After the morning orientation, all students flew to Visakhapatnam for the first week of field work. From January 3-8, students shadowed Dr. Nikhil and the UDAY team in Visakhapatnam, one of the sites wherein PHFI conducts diabetes and hypertension screenings. We had the opportunity throughout the week to meet a diverse array of representatives from the health system – patients, providers, women’s groups, and health workers, from urban, rural, and tribal settings. Divided into groups of five students, we met daily with various representatives from the community during question and answer sessions lasting from approximately 30 minutes to one hour. We also observed a mobile community engagement event spearheaded by PSI to raise awareness of cardiovascular disease. The trip was complemented by an exploration of some of the cultural elements of India –joggers and walkers starting their morning by the beach, yoga at dawn, shoppers preparing for the Visakha Utsav festival, and a trip to the famous Borra caves. See Table 1 4 for a detailed description of Vizag itinerary. From January 9-13, we complemented our south India experience by visiting Sonipat, a city two hours north of Delhi. The stay began with an in-depth presentation on the structure of India’s healthcare system and the National Rural Health Mission. We then spent the next week meeting with patients, providers, managers, schoolchildren, health workers, and government representatives across both public and private systems. Primary activities included a meeting with district health authorities, a visit to the anganwadi, and consultation with medical officers at a primary health center, a private hospital, and a community health center. Each day ended with a debrief led by Dr. Prashant at the PHFI field office to reflect upon daily activities. See Table 2 for a detailed Sonipat itinerary. After a 5-day break during which time students were free to travel, the trip concluded with a debrief at the PHFI Gurgaon office with Dr. Cash and Dr. Mohan to reflect upon the experience and share suggestions program improvements. These recommendations are summarized below for consideration as adaptations to next year’s winter session. Overall Impressions The program provided an excellent overview of India’s health system and approaches to combatting diabetes and hypertension from a variety of perspectives: patient, provider, health worker, urban, rural, tribal, public, and private. Visiting both a south Indian and north Indian site exemplified India’s heterogeneity and the resulting unique challenges faced at different locations in terms of culture, diet, infrastructure, and values. PHFI, in tackling such a large-scale project (screening every adult over the age of 30 in each catchment area) demonstrated significant creativity in addressing unique site challenges. Both teams were committed to ensuring local investment in UDAY’s work by recruiting and training local healthcare workers, identifying community members to serve as positive deviant examples amongst their peers, and scheduling regular mobile clinic activities to raise awareness of diabetes and hypertension. The Harvard cohort was impressed by the level of rapport that had clearly developed between UDAY site leaders and local community officials, as well as the high 5 level of general community buy-in and involvement in UDAY’s work. The site teams in Vizag and Sonipat developed thoughtful and comprehensive itineraries for the winter session students; all transportation, community meetings, and activities were well-organized and impeccably executed. The students also greatly appreciated PHFI’s decision to divide the group into two teams of five students each. This was an ideal number per site visit to facilitate connection and more fruitful conversation with community representatives