Volume 90 No. 11 November 2007

Brown In the Lesser Developed World

UNDER THE JOINT VOLUME 90 NO. 11 November 2007 EDITORIAL SPONSORSHIP OF: Medicine
Health The Warren Alpert Medical School of Brown University HODE SLAND Eli Y. Adashi, MD, Dean of Medicine R I & Biological Science PUBLICATION OF THE RHODE ISLAND MEDICAL SOCIETY Rhode Island Department of Health David R. Gifford, MD, MPH, Director COMMENTARIES Quality Partners of Rhode Island 338 Personal Reflections On This Issue Richard W. Besdine, MD, Chief Medical Officer Joseph H. Friedman, MD Rhode Island Medical Society 339 The Serendipitous Gift of Epiphany Barry W. Wall, MD, President Stanley M. Aronson, MD EDITORIAL STAFF Joseph H. Friedman, MD CONTRIBUTIONS Editor-in-Chief Joan M. Retsinas, PhD Brown In the Less Developed World Managing Editor Guest Editors: Susan Cu-Uvin, MD, and David Pugatch, MD Stanley M. Aronson, MD, MPH 340 A Message From the Dean Editor Emeritus Eli Y. Adashi, MD EDITORIAL BOARD 340 Brown’s Involvement In the Health of Less Developed Countries Stanley M. Aronson, MD, MPH Susan Cu-Uvin, MD, and David Pugatch, MD Jay S. Buechner, PhD John J. Cronan, MD 342 Brown’’s Fogarty International Center AIDS International Research and James P. Crowley, MD Training Program: Building Capacity and New Collaborations Edward R. Feller, MD John P. Fulton, PhD Kenneth H. Mayer, MD, and Eileen Caffrey Peter A. Hollmann, MD 346 The Dual Burden of Infectious and Non-Communicable Diseases in the Sharon L. Marable, MD, MPH Anthony E. Mega, MD Asia-Pacific Region: Examples from The Philippines and the Samoan Islands Marguerite A. Neill, MD Jennifer F. Friedman, MD, MPH, PhD, Jonathan D. Kurtis, MD, PhD, and Frank J. Schaberg, Jr., MD Stephen T. McGarvey, PhD, MPH Lawrence W. Vernaglia, JD, MPH Newell E. Warde, PhD 351 Perspectives From Brown Medical Students and a Medical Resident David Sears, MD, E. John Ly, BMS IV, Natasha Rybak, MD OFFICERS Nick Tsiongas, MD, MPH 358 Brown In Kenya President Edward J. Wing, MD Diane R. Siedlecki, MD President-Elect 360 Caring for HIV-Infected Refugees In Rhode Island Vera A. DePalo, MD Simon Dejardins, Curt G. Beckwith, MD, Heather Ross, LCSW, Vice President Lauri Bazerman, MS, Jennifer A. Mitty, MD, MPH Margaret A. Sun, MD Secretary Mark S. Ridlen, MD COLUMNS Treasurer 363 THE CREATIVE CLINICIAN – Tuberculosis Peritonitis Barry Wall, MD Joseph D. DiMase, MD, FACG, FACP, and Deepak Agrawal, MD Immediate Past President 365 HEALTH INSURANCE UPDATE – HEALTHpact Plans for Small Employer: DISTRICT & COUNTY PRESIDENTS Physician’s Role Geoffrey R. Hamilton, MD Matthew Stark Bristol County Medical Society Herbert J. Brennan, DO 367 HEALTH BY NUMBERS – Refugee Health Update: Lead Exposure in Kent County Medical Society Refugee Children Rafael E. Padilla, MD Pawtucket Medical Association Maria-Luisa Vallejo, MA, MEd, MPH, Carries Bridges, MPH, Patrick J. Sweeney, MD, MPH, PhD Magaly Angeloni, MBA, and Peter R. Simon, MD, MPH Providence Medical Association Nitin S. Damle, MD 369 LETTERS Washington County Medical Society 370 PHYSICIAN’S LEXICON – The French Connection Jacques L. Bonnet-Eymard, MD Woonsocket District Medical Society Stanley M. Aronson, MD Cover: “Marché Mouffetrard,” by Areg 370 Vital Statistics Elibekian, Oil on Canvas, 8 x 10 inches. The artist graduated from Yerevan’s Institute of 372 November Heritage Drama & Fine Arts in 1992. His works were part of the Elibekian family exhibitions at the Medicine and Health/Rhode Island (USPS 464-820), a monthly publication, is owned and published by the Rhode Island Medical Society, 235 International Art Center in Beirut, Lebanon, Promenade St., Suite 500, Providence, RI 02908, Phone: (401) 331-3207. Single copies $5.00, individual subscriptions $50.00 per year, and $100 ALMA Gallery in Boston, Massachusetts, per year for institutional subscriptions. Published articles represent opinions of the authors and do not necessarily reflect the official policy of the Rhode Island Gallery L’Oeil Reno Berg, in Brussels, and Stu- Medical Society, unless clearly specified. Advertisements do not imply sponsorship or endorsement by the Rhode Island Medical Society. Periodicals postage dio 22, in Antwerp, Belgium. In 1998, he had a paid at Providence, Rhode Island. ISSN 1086-5462. POSTMASTER: Send address changes to Medicine and Health/Rhode Island, 235 Promenade St., solo exhibition at the Gallery Hai Cie in Paris. Suite 500, Providence, RI 02908. Classified Information: RI Medical Journal Marketing Department, P.O. Box 91055, Johnston, RI 02919, He was recently a part of the Three Genera- phone: (401) 383-4711, fax: (401) 383-4477, e-mail: [email protected]. Production/Layout Design: John Teehan, e-mail: [email protected]. tions of Armenian Art show at Gallery Z in 337 Providence. www.galleryzprov.com VOLUME 90 NO. 11 NOVEMBER 2007 Commentaries

productive doing there, which was teaching. I was a visiting professor, seeing patients, teach- Personal Reflections On This Issue ing housestaff and a few students the basics of  neurology. It was rewarding for me, although less so for the patients who were rarely diag- I generally do not tailor my monthly column cal medicine scholarships as the previous year’s nosed, and even less commonly treated for to the topic of the journal. Since the topics that one hadn’t been used, and I increased my debt. anything. Nevertheless, neurology is an im- I choose to write about enter my consciousness It was worth every penny of the principal and portant discipline for doctors in the third in a random, uncontrolled manner, I find my- the interest, profound or not. world to know. Epilepsy, in particular is a very self unable to choose a topic, like the topic the I helped in the OR, and I “ran” a TB serious problem which leads to a large num- particular issue is devoted to. This issue was no ward for adults and one internal medicine ber of injuries, with people falling into open exception until I read the student’s article that ward, under the supervision of a British doc- cooking fires, or out of canoes. Mental illness began with a case of tetanus. tor. Since I was in the last three months of is virtually untreated. In Zambia there was a Tetanus is engraved in my memory as medical school they gave me a fair amount single psychiatrist in the country, and he was well. of responsibility after I acclimatized and they an elderly expatriot who had been trying to I first went to Africa in 1969. I spent got the measure of my capabilities. retire for several years. In a town near a major two years as a Peace Corps volunteer, teach- I also took call, which meant getting tourist attraction there is a one room hut, with ing high school math and math pedagogy at roused when someone came in after the clin- a lock, for any insane villagers to be kept until a teacher-training college in the northern re- ics closed. I remember vividly the night I was they can be sent to the single psychiatric hos- gion of Ghana, a place considered “bush” by on call and saw a young woman who couldn’t pital in the country. the people who lived in the more developed, open her mouth. In an experience that was I plan to spend a month teaching in and richer, southern regions. It was this expe- almost hallucinatory, I heard one of my medi- Kenya in one of the Brown programs in early rience that triggered my interest in medicine. cal school neurology attendings, a Ghana- 2008. I’ve reserved the month and will go I returned to Africa in 1978 to com- ian working in the US, say, “whenever you with my medical student daughter. I wish I plete my last three months of medical school. see someone who can’t open their mouth, could stay longer. I plan, when I have no chil- I worked/studied in the bush of Tanzania, at think of lockjaw and look for a sore.” I looked dren in college, to create a job where I spend the hospital of the Medical Missionaries of for the sore, and found it on the leg. I then part time in Rhode Island and part time some- Mary, a wonderful group of Irish nuns. As noticed not only the lockjaw, but the where in Africa. I don’t know where. To be my teaching assignment in Ghana was at the opisthotonus as well. She died, of course. honest, I can probably do more “good” by Men’s Evangelical Presbyterian Teacher Back in the days before AIDS, we making as much money here as I can and Training, it was ironic that I, a Jewish boy washed our hands before spinal taps but donating it to Doctors Without Borders, or from the Bronx, would now work at a hos- didn’t use gloves. We reused needles after to Paul Farmer, but there is a role, too, for pital run by nuns, after teaching at a school cleaning and autoclaving, and reused surgi- those of us who like to move into other cul- run by evangelical Presbyterians. cal gloves after washing and sterilizing as well. tures, expand our own frontiers, and hope- I first heard about the hospital from the We had a truck headlight attached to a bat- fully help some people as we do it. chief resident in internal medicine at Harlem tery for a surgical light. Patients were carried The Brown programs described in this Hospital when I was a student. It sounded by stretcher from untold miles away, down issue excited me. I am happy that we have perfect for me and I arranged a position, the cliff at the edge of the Rift Valley. Pa- people doing things like this in our commu- with my medical school’s cooperation, for a tients brought their own food and families nity. I am particularly happy that their spirit fourth year elective. The school had a schol- did a lot of the nursing care. has been taken up by their students. The apple arship for tropical medicine, which I applied I was mildly scolded for donating my doesn’t fall far from the tree, I am happy to for and got, but it wasn’t very much money. own blood to a patient slowly exanguinating observe. Good doctors make good doctors. I appealed to the head of the tropical medi- from TB. It was “wasted,” they correctly ob- cine department for more financial help. The served. I helped a teenage girl with rabies – JOSEPH H. FRIEDMAN, MD trip alone was a budget buster. die without pain. I watched a dead baby, “Are you in profound debt?” he asked. stuck part way out of the vagina in a birth Disclosure of Financial Interests I was surprised. This was a personal that began far away and failed to complete, Joseph Friedman, MD, Consultant: question, phrased in a very odd, rather liter- get dismembered with a shears so that it Acarta Pharmacy, Ovation, Transoral; ary manner. could be withdrawn from the birth canal. Grant Research Support: Cephalon, “As a matter of fact, I am.” Yet I still became a neurologist, a fairly Teva, Novartis, Boehringer-Ingelheim, “Then a little more won’t matter very useless occupation for these people. I had al- Sepracor, Glaxo; Speakers’ Bureau: Astra much, will it?” ways intended to go back to someplace in Zeneca, Teva, Novartis, Boehringer- Twenty seven years later I still can’t decide Africa, and I finally got a chance a few years Ingelheim, GlaxoAcadia; Sepracor, if this was a sage question or not. I got two tropi- ago to do the only thing a neurologist can be Glaxo Smith Kline 338 MEDICINE & HEALTH/RHODE ISLAND The Serendipitous Gift of Epiphany

The Greeks defined epiphany as the sudden emergence of phthalein was chosen since it imparted a wine-like color to the something important, the transformation of something banal adulterated product. Shortly after distribution of the synthetic into a special, perhaps memorable, event, or the unforeseen wine, an epidemic of unexplained diarrhea erupted amongst appearance of something glorious, perhaps even divine. Since consumers. It did not take long for the vintners to appreciate then, as with so many words of Classical origin, epiphany has that the phenolphthalein was responsible. Within another de- taken on a number of divergent meanings. cade this agent, first isolated by Perkin as a textile dye, became To theologians, epiphany has come to mean a manifesta- the world’s most popular laxative in such proprietary pharma- tion of a divinity, a spiritual revelation. The Christian festival of ceuticals as Feen-A-Mint and Ex-Lax. the Twelfth Night [January 6], called the Epiphany, celebrates To the scientist, an epiphany is a unique spiritual happen- the disclosure of Christ’s divinity before the Magi. ing when some unevoked reasoning transiently illuminates a Epiphany is a resplendent noun, resonant with meaning, previously enigmatic path, when the tension between the in- glorifying anything that the writer feels is deserving of extreme tuitive and the rational is not ignored. It represents the highest reverence. And to scientists it has come to mean that rare but emotional peak achieved by a scientist; and it arises when, dur- exultant moment during the course of lengthy experimenta- ing the course of extended experiments, the underlying physico- tion when an underlying physical principle or fundamental chemical principle governing the experiments suddenly be- explanation suddenly leaps into consciousness. comes apparent, when the dots become connected. To a seren- Both epiphanies and serendipities share the joys of sud- dipitous event, the scientist will exclaim: “Wow,” or “Holy den revelation; but to the scientist, there are differences. Ser- mackerel!!” or “Gee, how do I account for this ?” But to a sci- endipity is the revelation which materializes while the scientist entific epiphany, on the other hand, she might utter: “Aha!” is pursuing another experiment. It represents an uncomfort- or “Eureka!” able aberration in the generated data which is contrary to ex- Apples have been falling for millennia without exciting pectations. This will be treated by some as an intrusive annoy- people to dwell upon the dynamic reasons underlying their de- ance; but to others, the more creative ones, it will represent a scent. Then, an Englishman named Newton, perceived that startling answer to a question which had not even been asked. something was operative, something more than the banal reality An industrial scientist, for example, starts out to seek a more that objects in space, when untethered, tend to fall rather than efficient lubricant but ends up with a strange substance in his rise. But further, he saw the commonality between the descent test tube, a substance which, with further exploration, turns of the apple and that invisible force called gravity holding plan- out to possess wondrously adherent qualities, a superglue. This ets in their celestial orbits; and further, the epiphany that this is serendipity and it marks the careers of those with sufficient force called gravity abided by precise mathematical rules. courage to seek out anomalies.. Scientists have traditionally distinguished between discov- Serendipity is sometimes reached through mishap rather ery, invention and creativity. Root-Bernstein, the physiologist, than meticulous planning. Consider, for example, the profes- once declared: “We invent by intention; we discover by sur- sional career of William Henry Perkin [1838 – 1907], born in prise.” Yet others interested in the philosophic underpinnings East London, the gifted son of a journeyman carpenter. Young of science propose a hierarchy of challenges in the basic sci- Perkin attended the Royal College of Chemistry and was as- ences: There is first, discovery, which they define as disclosing signed the task of synthesizing quinine, then an exorbitantly something which always existed but had never previously come expensive medication needed by Britain as it embarked upon to the attention of the community of scientists. [Thus, America its imperialist expansion in Africa and Asia. was discovered; although America had always existed.] And Perkin was unsuccessful in synthesizing quinine but in his then there is invention defined as the conscious assemblage of studies of coal tar derivatives, he isolated a brilliant purple dye technical products yielding a completely new gadget. [The in- which he called Mauveine. When applied to raw silk, it was ventive mind of Edison led to such innovative products as the color-fast. Perkin patented his discovery [at age 18] and went electric light bulb and the phonograph.] An finally, there is on to become Britain’s leading industrial chemist, discovering the creative mind, the mind capable of envisioning bold but countless dyes which allowed England to compete effectively inapparent connections and theories which bring together and with Germany in the lucrative textiles industry. One of the serve to explain ostensibly unrelated natural phenomena. many coloring substances isolated by Perkin was a curious What are the practical differences between serendipity and chemical called phenolphthalein. No textile use was found for epiphany ? Seeking stray coins in the street and finding, in- it and so it languished for years until the first decade of the stead, a lottery ticket is serendipity. If the lottery ticket is a win- 20th Century when the Hungarian vineyards were attacked ning one, that is epiphany. by a pestilence which almost destroyed Hungary’s wine indus- try. Until new vineyards could be established, the local winer- – STANLEY M. ARONSON, MD ies resorted to making artificial wines, a combination of water, grain alcohol and fruit juices. The artificial wines, however, Disclosure of Financial Interests needed a vivid coloring agent; and after many trials phenol- Stanley M. Aronson, MD, has no financial interests to disclose. 339 VOLUME 90 NO. 11 NOVEMBER 2007 A Message From the Dean Eli Y. Adashi, MD Developing countries throughout the world are afflicted engaged in global health efforts, a contingent representing 13 with a multitude of parasitic and infectious diseases for which academic departments and over $12 million in peer-reviewed the diagnosis, treatment and prevention are still very much funding. Overall, we are stretched across 5 continents and 28 wanting. For the past twenty years, Brown University’s faculty, countries. fellows, residents, medical and undergraduate students have There is much work left to be done. In the coming year, participated in a variety of efforts throughout the globe to treat and with Brown University President Ruth Simmons’ focus on patients, train overseas physicians and medical professionals, the internationalization of the University, we will expand and and develop delivery protocols addressing social and cultural coordinate our global health efforts by identifying opportuni- barriers to treatment and prevention. ties for interdisciplinary research and collaboration so as to le- Much of Brown’s participation in the global health front verage our collective resources to promote well-being for all. began as a volunteer effort supported by private contributions of resources and time by our faculty and students. These ef- Eli Y. Adashi, MD, is Dean of Medicine & Biological Sci- forts have grown into established collaborations and programs ence, the Warren Alpert Medical School of Brown University. with clinics and hospitals, educational institutions, and gov- ernments in various corners of the developing world. Today, Disclosure of Financial Interests Brown University boasts 55 faculty members who are actively Eli Y. Adashi, MD, has no financial interests to disclose. Brown’s Involvement In the Health of Less Developed Countries Susan Cu-Uvin,MD, and David Pugatch,MD

This issue of Medicine& Health/ Rhode tes and coronary vascular disease, are mak- neth Mayer and Eileen Caffrey sum- Island is devoted to the involvement of the ing their way into the populations of less marize the 12-year experience of Warren Alpert Medical School commu- developed countries.1 Brown’s AIDS International Re- nity in global health. Represented in this An over-arching theme runs through search and Training Program, spon- issue are a sampling of the projects and these articles: faculty and students at Brown sored by Fogarty International Cen- collaborations, representing the remark- perceive a responsibility to help the less for- ter of the National Institutes of Health. able efforts and commitment of faculty tunate peoples of the world. This comes, at This program, involving both hospi- and trainees of all levels. These reports least in part, from an awareness that the tal-based and campus-based Brown from the field demonstrate the ways in health disparities between developed and less faculty, has trained more than 50 which global health activities have been developed countries are significant and un- scholars in HIV/AIDS research from integrated into our mission as researchers, acceptable. For example, 89% of the world’s five Asian countries. After periods of medical educators and clinicians. population lives in countries that bear 93% training at Brown and the Miriam Why the proliferation of global health of the world’s disease burden. However, they Hospital , trainees from Philippines, projects? Perhaps physicians and research- account for only 11% of the world’s health Cambodia, India , Indonesia, Kenya, ers have come to recognize what economists spending. The chance of dying from preg- and Bangladesh return to their home have known for decades: that our world has nancy-related causes for a woman in a less countries to build local capacities. become increasingly interdependent. Com- developed country is 38 times that for a municable diseases, such as HIV, multi- woman in a developed one. Additionally, less + Drs. Jennifer Friedman, Jake Kurtis drug resistant tuberculosis, SARS and pan- developed countries bear 99% of the bur- and Stephen McGarvey have demic influenza, are an airplane ride away. den of global maternal deaths.2 worked with investigators at the Re- As the populations of the world migrate search Institute of Tropical Medi- across national borders, diseases are carried These articles highlight the differ- cine in Manila, to elucidate the to new locations. Thus, it is hardly surpris- ent roles of faculty and students: pathogenesis, disease burden, and ing that, each day, Rhode Island physicians ecological factors in transmission, of see diseases of the less developed world at + Programs at the Warren Alpert Medi- a common yet poorly understood the clinic or hospital. Conversely, as a result cal School of Brown University are parasitic infection- Schistosomiasis. of globalization and lifestyle modernization, helping countries to build capacity Their work, funded by the National the common chronic diseases of the west- and infrastructure to address epi- Institutes of Health (NIH), has ern sedentary world such as type II diabe- demic infectious diseases. Dr. Ken- shed light on the role of pro-inflam- 340 MEDICINE & HEALTH/RHODE ISLAND matory cytokines in mediating the disease outcomes seen REFERENCES due to infection by S. Japonicum, and the role of other 1. Anderson GF, Chu E. Expanding priorities. NEJM 356;3; 209. mammals in maintaining transmission. 2. Satcher D. From the Surgeon General: Eliminating Global Health Disparities. JAMA 2000;284: 2864. 3. Sachs JD. The End of Poverty, Economic Possibilities for Our Time. Penguin Press, + Professor Stephen McGarvey discusses the twin epidem- 2005. ics of obesity and type II diabetes mellitus among of the populations of the Samoan Islands. His work over the Disclosure of Financial Interests past three decades details the health transition typical of Susan Cu-Uvin, MD. Advisory Board: Bistol Myers Squibb, many modernizing populations from a predominance of Boehringer Ingelheim, Evo Pharmaceutical, Merck. Grant Research morbidity from infectious diseases to an emerging impor- Suport: Bristol Myers Squibb. Speakers’ Burea;: Boehringer tance of chronic non-communicable diseases that typify Ingelheim. Other financial or material interest: Merck. populations of the western world. David Pugatch, MD. Speakers’ Bureau: Merck, Inc.

+ Medical students Natasha Rybak, John Ly and medicine Susan Cu-Uvin, MD, is Director, The Immunology Center, resident David Sears highlight the educational value of The Miriam Hospital, and Professor, Obstetrics-Gynecology and experiences in international medicine. Each reported back Medicine, The Warren Alpert Medical School of Brown University. from lesser developed countries (Burundi, the Domini- David Pugatch, MD, is Director, Pediatric and Aolescent HIV can Republic and Cambodia). They considered the ro- Program, Division of Pediatric Infectious Disease, Hasbro Children’s tations “life-changing.” The opportunity to work within Hospital, and Associate Professor of Pediatrics and Medicine, The a less developed country’s healthcare system provides train- Warren Alpert Medical School of Brown University. ees with a broadened view of medicine’s cultural context. CORRESPONDENCE Additionally, medical trainees who undertake global health Susan Cu-Uvin, MD electives in less developed countries benefit from medical learning The Miriam Hospital opportunities which could only be had outside of the United States. 164 Summit Ave. Students and residents encounter diseases commonly seen in the Providence, RI 02906 United States, such as pneumonia or cancer, but at a very late Phone: (401)793-4775 stage of presentation. They learn about tropical diseases, such as e-mail: [email protected] malaria, schistosomiasis and dengue fever, that are occasionally seen in Rhode Island. They re-discover the value of the stethoscope, learning that medicine can be practiced rationally, judiciously and effectively in places without MRI and CT scanners.

+ Dr. Edward Wing, Chair, Department of Medicine , de- scribes the research and exchange collaboration in Eldoret, Kenya, and lists the rich international health opportunities available through the department of Medi- cine. He reminds us through his personal experience and commitment, that international medicine experiences are “life-altering” adventures which fundamentally change, for the better, our perception of medicine and the world. We return from resource-poor to us in the United States.

+ Simon Desjardins and colleagues, in their article on caring for HIV-Infected Refugees in Rhode Island, remind us that glo- bal health maladies exist here and now, in our own local prac- tices. The provision of healthcare to the refugees and immi- grants of Africa, Asia and Latin America challenges the clini- cal skills and cultural competence of the medical provider.

A passionate sense of moral obligation and humanitarian purpose permeates these articles. This obligation is perhaps sum- marized best by economist Jeffrey Sachs’ observation: “… certain parts of the world are caught in a downward spiral of impoverish- ment, hunger and disease. It is no good to lecture the dying that they should have done better with their lot in life. Rather it is our task to help them onto the ladder of development…from which they can then proceed to climb on their own.”3 341 VOLUME 90 NO. 11 NOVEMBER 2007 Brown’s Fogarty International Center AIDS International Research and Training Program: Building Capacity and New Collaborations Kenneth H. Mayer, MD, and Eileen Caffrey Brown University faculty have been involved Over the past 14 years, the Brown- eases 7 Nature Immunology,21 and AIDS- in infectious disease research in Asia, par- Tufts AITRP has trained more than 50 specific journals.22-25 ticularly in the Indian subcontinent, for Asian scholars, resulting in almost 100 The trainees have risen to promi- more than 40 years. In the 1960s, Dr. peer-reviewed publications and almost nence in the AIDS research and public Charles Carpenter conducted pivotal 200 presentations at recent international health infrastructures of their home studies to delineate the pathogenesis of conferences. Early trainees generated one countries: the YRGCARE Research acute diarrheal diseases in Calcutta, con- of the first reports that defined the preva- Laboratory in Chennai, India, which is tributing to the development of oral re- lence of a multiclade HIV epidemic in led by former trainees, has been desig- hydration therapy. Because of the in- the Philippines.1 Other studies described nated as a WHO antiretroviral resistance creasing demands of the global AIDS epi- the prevalence of HIV and STDs in preg- reference surveillance lab. One Brown demic and the recognition of the poten- nant women in the Philippines2 and In- AITRP trainee has been appointed as an tial for a rapid escalation of the epidemic dia,3 high risk heterosexuals in India,4 and Assistant Minister for Health in Cambo- in Asia, Dr. Carpenter led the Brown HIV prevalence in rural areas in India dia; several trainees are members on na- team to successfully apply for a Fogarty using dried blood spot technology.5,6 The tional AIDS advisory committees. Train- AIDS International Training and Re- increased clinical research capacity devel- ees have also been appointed as advisors search Program grant (D43TW000237) oped at several of our affiliated interna- to UNAIDS, IAVI, and the Gates and 14 years ago. The initial Brown AITRP tional sites led to the first reports of the Clinton Foundations, and have been in- focused on Brown’s training of clinical re- clinical impact of generic highly active volved in writing the WHO guidelines searchers in the Philippines and Indone- antiretroviral therapy (HAART) in In- for the use of antiretroviral compounds sia. The program has evolved, and been dia,7 resulting in decreased morbidity and in resource-constrained environments. A consistently funded, with successful re- mortality, while alerting clinicians to description of major national efforts is competitions in 2000 and 2005, led by drug-associated side effects.8,9 In another summarized below. Dr. Kenneth Mayer, who became the pivotal study, Brown AITRP Indian Principal Investigator for the AITRP in trainees demonstrated the presence of INDIA 1997. A strong collegial Executive Com- antiretroviral resistance mutations in YRGCARE has become a model mittee has included hospital-based clini- treatment-experienced and naïve pa- center for the provision of community- cal researchers: Drs. Carpenter, Timothy tients.10 Brown-Tufts Fogarty trainees based HIV care, with close to 10,000 in- Flanigan, Susan Cu-Uvin, David Pugatch described the etiology of HIV-associated dividuals diagnosed with HIV since the and Herb Harwell, as well as faculty from wasting and diarrhea, as well as con- inception of the organization more than Brown’s International Health Institute, ducted initial studies of the nutritional a decade ago, and more than 3,000 in- Drs. Stephen McGarvey and Mark and metabolic effects of generic HAART dividuals now receiving antiretroviral Lurie. in India.11,12 Trainees As increasing collaborations devel- have also been among oped in several other countries, the the first to describe the Fogarty AITRP expanded to train clini- use of low-cost clinical cal, laboratory and behavioral research- monitoring technologies ers from India and Cambodia. In 2000, to track the course of because of growing clinical research con- HIV infection and re- tacts, including collaboration in an inte- sponse to therapy.6,13-15 grated NIH Center for AIDS Research AIRTP trainees from (CFAR), the faculty of Tufts University/ this program conducted New England Medical Center, led by some of the first first Drs. Sherwood Gorbach and Christine clinical studies describ- Wanke, were asked to participate in the ing the natural history of Brown AITRP. This collaboration re- HIV disease in Cambo- sulted in enhanced training opportuni- dia.16-18 Papers by ties, particularly in the HIV and nutri- Brown-Tufts AIRTP tional research. Additional trainees from trainees have appeared Vietnam and Western Kenya were sup- in the Lancet, 19, 20 ported in 2006. Clinical Infectious Dis- Drs. Kenneth Mayer and N. Kumarasamy 342 MEDICINE & HEALTH/RHODE ISLAND therapy. YRGCARE has become an infection in HIV. She presented prelimi- the 2006 International AIDS Conference. NIH-funded AIDS Clinical Trials Unit nary results from this work at the 2004 The Brown-Tufts AITRP program and HIV Prevention Trials Unit; its meeting of the American Society of Tropi- helped to inaugurate the Fogarty-Ellison founder, Dr. Suniti Solomon, a Brown cal Medicine and Hygiene.27 Christian Medical Student Fellowship program in collaborator, has received NIH-funding Medical College in Vellore has been 2004, which has evolved into the Fogarty to study HIV-related stigma. YRGCare’s named a government of India ART roll- International Center Clinical Scholars lab director, Dr. Balakrishnan, has been out site, and AITRP trainees and collabo- Program (FICSP). Through this pro- funded by the NIH to study the genital rators have received a Planning Grant for gram, 8 American and 8 Indian medical tract responses of HIV-exposed, but Global Research in Infectious Disease and public health students have been uninfected women in serodiscordant re- Research (GRID) in South India, and an trained, spending a year overseas con- lationships. The collaboration has re- R03 to study the Molecular Epidemiol- ducting clinical research. They were sulted in more than 2 dozen joint publi- ogy of Cryptosporidiosis in South India mentored at Brown-Tufts AITRP-affili- cations, and more than 40 presentations for their work on the diarrheal diseases in ated sites at YRGCARE in Chennai and at international AIDS conferences. the setting of HIV. Another AITRP at Christian Medical College in Vellore, YRGCARE has a free-standing institu- trainee from CMC Vellore, Jessie Lionel, India. Trainees have worked on a range tional review board (IRB) and an active an obstetrician-gynecologist, is assessing of projects, including primary data analy- community advisory board (CAB), and the prevalence of HIV infection among ses, field and laboratory work, and have has been integrated into the HIV Pre- pregnant women in local urban and ru- assisted in the evaluation of natural his- vention Trials Network, conducting stud- ral areas. tory data. ies of HIV seroprevalence and incidence The Brown-Tufts AIRTP has also de- (HPTN 033) in high-risk populations veloped a robust training collaboration PHILIPPINES with Dr. Suniti Solomon as the site PI.22- with the Indian Council for Medical Re- Brown faculty have been working 25 An AITRP funded sub-study that search-affiliated TB Research Center with clinical investigators from the Uni- evaluated the prevalence of sexually trans- (TRC) under the leadership of Dr. versity of the Philippines for over two de- mitted infections in Chennai found that Soumya Swaminathan. One of her col- cades. In 1992, a World AIDS Founda- more than 30% of the men and women leagues, Geetha Ramchandran, PhD, tion grant allowed the first HIV/AIDS recruited in the study were infected with learned new pharmacologic evaluation trainees to come to Brown. The primary Herpes simplex Type 2.26 Among the techniques to be able to do assays of ge- area of emphasis was HIV prevention. women, almost 10% had trichomonia- neric antiretroviral therapy to establish Since then, more than 20 trainees have sis, and syphilis was almost equally preva- bioequivalency.28 From this training, she come to Brown for HIV/AIDS training lent. An R21 funded by NIH/NIMH has established facilities at the TRC to ex- under the Fogarty grant. The trainees (Dr. T. Flanigan, PI) was awarded to amine the interaction of antituberculous have included physicians, and other cli- Brown and YRGCare to investigate the and antiretroviral medications in common nicians, social and behavioral scientists, neurocognitive consequences of HIV/ usage in South India. administrators, as well as basic scientists. AIDS in South India. Suneeta Saghyam, Another major focus of our training Studies by Brown-Tufts Fogarty trainees MSc, a nutritionist at YRG, has initiated program for Indian colleagues has been in the Philippines have focused on the a project that is examining the impact of microbicide research. In 2002, the determination of the prevalence of HIV the initiation of generic NNRTI based Brown-Tufts AIRTP hosted two clinical infection among 3,000 pregnant women HAART on the nutritional and metabolic investigators, Drs. Kamini Walia and at the Philippine General Hospital,2 the status of HIV-infected adults at YRG Nomita Chandhiok from the Indian assessment of knowledge, attitudes, be- CARE. She has presented preliminary Council for Medical Research (ICMR) liefs, and behavior among health care data at the Bangkok International AIDS in New Delhi, to learn immunological workers involved in the care of HIV/ Conference Meeting12 and the Interna- techniques to be able to assay genital AIDS patients.29 the prevalence of high- tional Lipodsytrophy Meetings in 2004 cytokines as surrogate markers to evaluate risk behaviors and sexually transmitted and 2006. mucosal toxicity in clinical microbicide diseases among women prisoners at the Although antiretrovirals are available studies, as well as to learn principles of clini- state penitentiary in Metro Manila,30 the at relatively low cost in India, their use is cal microbicide trial design. Most recently, expression of Human immunodeficiency not universally common. The most com- Brown-Tufts AIRTP developed relation- virus in the plasma and cervicovaginal mon presentations of HIV/AIDS in In- ships with several teaching hospitals in secretions in Filipino women,31 the preva- dia include wasting, respiratory and diar- Mumbai. Sameer Kumta, a physician lence of HIV among patients hospital- rheal diseases. With the support of Fogarty trained in Infectious Diseases and Public ized for acute Pelvic Inflammatory Dis- AITRP, Dr. Gangadeep Kang of Chris- Health posted at the Mumbai District ease,32 and the prevalence of lower geni- tian Medical College in Vellore has trained AIDS Control Society (MDACS), com- tal tract infections among HIV-infected investigators to evaluate intestinal func- pleted the MPH program at Brown Uni- and high risk uninfected incarcerated tion and diarrheal pathogens in HIV-in- versity this past year. His thesis examined women.33 Other studies have evaluated fected patients. Dr. Kang is the PI for an the secular trends in HIV and STD inci- the effectiveness of peer counseling by AITRP-funded protocol to investigate the dence among MSM in Mumbai over the video versus face-to-face on the knowl- molecular epidemiology of cryptosporidial past decade; the data were presented at edge, attitudes, and practices of Filipino 343 VOLUME 90 NO. 11 NOVEMBER 2007 a lack of treatment re- established a women’s HIV Clinic in Cen- sources and a high mor- ter of HOPE, in Phnom Penh, and a tality rate, the prevalence Fogarty International Research Collabo- of HIV infection in Cam- ration Award (FIRCA) has been funded bodia has gradually de- for this women’s clinic to study the de- clined to its current level terminants of genital tract subtype AE of 2.6%. HIV-1 shedding among women initiat- Because of a rising ing generic antiretroviral therapy. Dr. HIV prevalence in Kruy Lim, a recent AITRP trainee, has women in Cambodia, developed a research proposal to further our trainees’ initial ef- describe the spectrum of cervical dyspla- forts focused on sia among women followed through these Drs. Kenneth Mayer, Suniti Solomon, and Charles Carpenter seroprevalence of HIV programs. AITRP trainee, Dr. Thai among pregnant women Sopheak has developed a project to evalu- commercial sex workers,34 the presence in Sihanoukville.17 This study estab- ate smear negative TB/HIV co-infected of antiretroviral drug resistance among lished a seroprevalence rate of 4.2% patients. One Center of HOPE trainee, recently diagnosed treatment-naïve HIV- among 600 consecutive parturient Sok Phan, completed the Masters of Pub- infected individuals in the Philippines,35 women who delivered their babies at lic Health program at Brown and a phy- and the transmission of HIV-related tu- Sihanoukville General Hospital, justi- sician from the Ministry of Health, Kim berculosis.36 The Brown-Tufts AIRTP has fying expansion of pMTCT intervention Bunna, is currently enrolled in the Brown trained health care professionals in HIV/ programs to provincial areas. A second MPH program. AIDS-related research from 4 teaching Brown trainee, Dr. Seng Sutwantha, hospitals in Manila as well as from the from the National Center for HIV, INDONESIA Department of Health. Many of the AIDS, Dermatology and STD The Brown-Tufts AIRTP began its trainees are also involved with several (NCHADS), evaluated key outcomes in collaborations in Indonesia in Yogykarta, non-governmental organizations. The the first MTCT pilot prevention project at Gadja Madah University, under the AIRTP grant has also been instrumental in Cambodia, implemented at hospitals aegis of Dr. Tony Sadjimin, the Director is training Dr. Agdamag, the lead virolo- in Phnom Penh and Battambang. Ad- of the Clinical Epidemiology and Biosta- gist at the San Lazaro STD/AIDS Co- ditional training and studies have exam- tistics Unit, resulting in the training of 6 operative Central Laboratory (SACCL) ined the etiology of chronic diarrhea in clinical investigators from Javanese Uni- in plasma HIV RNA quantification, HIV-infected in-patients, the spectrum versities. One of the collaborative antiretroviral resistance testing and clade of opportunistic infections,18 and the projects was a sero-surviellance study of analysis. etiology of meningitis16 among hospital- HIV and syphilis among commercial sex ized AIDS patients in Phnom Penh at workers in Central Java.37 In the past few CAMBODIA the Preah Bat Norodon Sihanouk Hos- years, training efforts have increased in Fogarty trainees in Cambodia, in pital. Collaborations now include the Bali, because of the rapid spread of the conjunction with collaborators at Brown National Pediatric Hospital in Phnom AIDS epidemic there. Brown worked and the Cambodian Ministry of Health, Penh, where studies are examining a di- with two professors from Udayana Uni- received funding from the World AIDS agnostic algorithm for HIV-exposed versity in Bali, Dr. Tuti Parwarti and Dr. Fund to train physicians in the care of newborns enrolled in a pilot mother-to- Dewa Nyoman Wirawan, and two of HIV-infected women and to create a re- child prevention project. Another their junior faculty, Dr. Asep Purnama ferral clinic for HIV-infected women in trainee at the National Pediatric Hospi- and Dr. I. Gusti Sumantera, have re- Phnom Penh. Several of the Brown tal, Dr. Sam Sophan, is conducting a ceived training fellowships at Brown. Dr. Fogarty-affiliated sites helped to found study of directly observed antiretroviral Sumantera developed a Fogarty AIRTP- the amFAR TREATAsia observational da- therapy for children. Pediatric collabo- funded project to evaluate the role of tabase, the first multinational profile of rative relationships have developed as medical incentives, such as free sexually the changing HIV/AIDS epidemic in well with the Angkor Hospital for Chil- transmitted diseases and hepatitis screen- Asia, which has subsequently received dren in Siem Reap, where a study of ing for injecting drug users, in order to NIH support. The first case of HIV in- nutritional assessments in HIV-infected increase patients’ willingness to be tested fection in Cambodia was detected in children is being developed by trainee for HIV. The project enrolled more than 1991. The Cambodian Ministry of Soeung Seithaboth. Another collabora- 200 participants; and the preliminary re- Health undertook annual sero-surveil- tive site, the Sihanouk Hospital Center sults, presented at international confer- lance and behavioral surveillance among of HOPE, has completed a cross-sec- ences, are now in press.38 Political unrest risk groups around 1995. Since then, the tional study of stage of disease among in Indonesia has slowed recruitment and prevalence of HIV infection in the gen- newly diagnosed patients. training activities, but new Indonesian eral population peaked in 1997, at With the help of the Lifespan/Tufts/ trainees are anticipated in the near fu- around 4%. With an aggressive strategy Brown CFAR and the World AIDS ture. of prevention interventions, coupled with Foundation, Drs Cu-Uvin and Harwell 344 MEDICINE & HEALTH/RHODE ISLAND KENYA REFERENCES 26. Kumarasamy N, Balakrishnan P, et al. Prevalence Because of the extensive collabora- 1. Santiago ML, Santiago EG, et al. J Acquired Im- of sexually transmitted infections among indi- viduals at high risk for HIV in Chennai, India- tions developed by Dr. E. Jane Carter, mune Deficiency Syndromes & Human Retrovirol 1998;18:260-9. Implications for HIV prevention. ISSTDR Con- the Director of Brown University’s TB 2. LM Gonzales, Manalastas R, et al. Prevalence of gress, July 27-30, 2003. Ottawa, Canada. Ab- program, and the academic alliance, human immunodeficiency virus infection among stract no: 355. AMPATH, based at Moi University in pregnant women at the Philippine General Hos- 27. Kang G. Molecular epidemiology of cryptosporidial infections in HIV infected indi- Eldoret, in Western Kenya, the Brown pital. Presented at the Second Conference on Global Strategies for the Prevention of HIV Trans- viduals in south India. American Society for Tropi- Fogarty AITRP recently expanded its mission form Mothers to Infancts, Montreal, cal Medicine and Hygiene Annual meeting. Mi- training activities there. The first two Canada, September, 1999. ami, 8 Nov 2004 Kenyan trainees, an obstetrician-gyne- 3. Madhivanan P, Hari A, et al. J Obstetrics Gynaecol 28. Ramachandran G, et al. Analysis of generic India 2002; 52: 43-7. antiretroviral formulations manufactured in In- cologist, Dr. Hillary Mabeya, and a pe- 4. Newman S, Sarin P, et al. Int J STD & AIDS dia (correspondence). AIDS 2004; 18:1482-4. diatrician, Dr. Esther Nabakwe, com- 2000;11:250-3. 29. Tayag JGT. Knowledge, Action and Commitment pleted several months of clinical research 5. Sunil Solomon, Suniti Solomon, et al. Int J STD for HIV/AIDS Prevention at the Local Govern- ment Level of the Philippnes: Imperatives and training at Brown. They have returned & AIDS 2002; 13:25-8. 6. Solomon SS, Pulimi S, et al. Int J STD & AIDS Lessons. Abstract MoPeF3928. Barcelona July 7- to develop new projects, and expand the 2004; 10: 658-61. 12 2002. already considerable Brown-Moi col- 7. Kumarasamy N, Solomon S, et al. Clin Infectious 30. Simbulan NP, Aguilar AS, et al. Social Science & laborations, which already have included Dis 2003: 36: 79-85. Med J 2001;52: 599-608. 31. Natividad-Villanueva G, Santiago E, et al. student exchanges, and visitors by senior 8. Kumarasamy N, Flanigan TP, et al. Lancet Infec- tious Dis 2002; 2, November 2002, Reflection Internat J STD & AIDS 2003;14: 826-9. faculty, such as Drs. Edward Wing and and Reaction section, http:// 32. Juliano-Remollino C. Seroprevalence of HIV Timothy Flanigan, in conjunction with infection.thelancet.com Infection Among Patients Admitted for Acute Dr. Carter. The Kenyan trainees will help 9. Kumarasamy N, Solomon S, et al. AIDS 2003; Pelvic Inflammatory Disease (PID) at the Philip- pine General Hospital. Asia-Pacific AIDS Con- to develop the research infrastructure 17: 2267-9. 10. Balakrishnan P, Kumarasamy N, et al. Clade C ference, Australia, 2001. needed for this tertiary center, which is HIV-1 antiretroviral drug resistance mutations in 33. Remollino C, Brown H, et al. J Correctional Health in the center of an area of high HIV treatment Naive Southern Indian patients. Care 2004; 10(4): 527-542. prevalence. [WePeB5715] Poster. XV Intl. AIDS Conf, 34. Hernandez L. Male Sex Workers in the Philip- Bangkok, 11-16 July 2004, accepted for publi- pines: Pleasures, Identities and Bodies relative to cation, AIDS Research & Human Retrovirus, 2005. HIV/AIDS, published by the University Center CONCLUSIONS 11. Saghayam S, Chaguturu SK, et al. CID 2004; for Women Studies, University of the Philippines Brown’s involvement in the Fogarty 38; 1646-7. (Correspondence). System, October 2004. AITRP has helped to train clinical inves- 12. Saghayam S, Kumarasamy N, et al. Metabolic and 35. Espantaleon A, Kageyama S, et al. Internat J STD body shape changes in a ART naïve-cohort initi- & AIDS 2003:14:125-31. tigators and leaders in the fight against ating generic HAART in South India. 36. Mendoza MT, Tan Torres T, et al. Phil J Chest AIDS in several Asian countries. At the [WePeB5923]. Poster. XV Intl. AIDS Conf, Diseases 2003;10: 78-84. same time, Brown students, residents, fel- Bangkok, 11-16 July 2004 37. Sugihantono A, Slidell M, et al. AIDS Patient Care & STDs 2003;17:595-600. lows and faculty have benefited from 13. Kumarasamy N, Mahajan AP, et al. JAIDS 2002;31: 378-83. 38. Sumantera GM, et al. AIDS Education and Pre- their immersion in dealing with the 14. Mahajan AP, Hogan JW, et al. JAIDS 2004;36: vention 2004; 487-498. emerging AIDS pandemic and associated 567-75. communicable diseases. These collabora- 15. Balakrishnan P, Dunne M, et al. JAIDS 2004; Kenneth H. Mayer, MD, is Professor tions have resulted in professional growth 36: 1006-10 - Basic Science. of Medicine and Community Health, The 16. Chhin S, Rozycki G, et al. Internat J STD & Warren Alpert Medical School of Brown locally and overseas, but also have re- AIDS 2004;15:48-50. minded the involved Brown community 17. Theng T, Sok P, et al. Internat J STD & AIDS (in University. members of the shrinking planet we share press) Eileen Caffrey is Project Director, with people living in dire circumstances 18. Chinn S, Mehta A, et al. Internat J STD &AIDS Brown-Tufts Fogarty AIDS International 2003; 14:41-6 Training and Research Program. a few plane rides away. 19. Kumarasamy N. Lancet 2004;364; July 3, 2004. Comment. 20. Shattock R, Solomon S. Lancet 2004;363, Com- DISCLOSURE OF FINANCIAL INTERESTS mentary. The authors have no financial inter- 21. Solomon S, Buck J, et al. Nature Immunol 2003; 4: 719-721. ests to disclose. 22. Kumarasamy N, Chaguturu S, et al. JAIDS 2004, 37(5):1574-1576. CORRESPONDENCE: 23. Kumarasamy N, .Biswas J, et al. AIDS 2000;14 Kenneth H. Mayer, MD Supplement 4; S68:179. 24. Kumarasamy N, Shyamprasad S, et al. J Assoc The Miriam Hospital Phys Ind(In press). 164 Summit Ave, RISE building, 25. Thamburaj EJ, Srikrishnan AK, et al. Challenges Room 112 in recruitment for research study at a Commu- Providence, RI 02906 nity-based Health Center in South India. [WePeE6806] Poster. XV Intl. AIDS Conf, phone ( 401) 793-4859 Bangkok, 11-16 July 2004. e-mail: [email protected]

345 VOLUME 90 NO. 11 NOVEMBER 2007 The Dual Burden of Infectious and Non-Communicable Diseases in the Asia-Pacific Region: Examples from The Philippines and the Samoan Islands Jennifer F. Friedman, MD, MPH, PhD, Jonathan D Kurtis, MD, PhD, and Stephen T. McGarvey, PhD, MPH Reduction of childhood mortality from into the liver causing periportal fibrosis japonicum. Most households do not have infectious diseases in developing nations (hepato-splenic disease) and eggs that dam- running water or electricity. Individuals has led to an increase in the proportion age the intestinal sub-mucosa as they mi- are infected as they cross waterways, dur- of adults in those populations and the grate through the intestinal wall to be passed ing rice farming, swimming, and doing consequent rise in non-communicable in stool. S. haematobium worms reside in domestic activities such as cleaning cloth- diseases (NCD). 1 This health transition the venous plexus surrounding the urinary ing and dishes in the streams. is happening globally at different rates, bladder. Pathology is caused by chronic in- In this study, we enrolled >500 chil- but one concern for medicine and pub- flammation and scarring of the bladder and dren and adults ages 8-30 infected with lic health is the dual burden of disease urogenital tract as eggs are passed through S. japonicum, treated them, and followed stemming from the still important infec- the bladder wall and out in the urine. Di- them quarterly for 18 months. At each tious diseases coexisting in nations, com- agnosis of schistosomiasis is made by exami- time, stool and blood samples were col- munities and families with the increase nation of stool (S. mansoni and S. lected and a physical examination was in NCD. 2 This dual burden is present japonicum) or urine (S. haematobium) for performed. Three weeks after treatment, throughout the world. the presence of eggs. peripheral blood mononuclear cells were We feature here two examples in the An 85% of the infected population collected and stimulated with S. Asia-Pacific region: schistosomiasis in The lives in sub-Saharan Africa, where S. japonicum vaccine candidates so the re- Philippines and cardiovascular diseases in haematobium, and S. mansoni are en- sponses could be correlated with the de- the Samoan Islands. Brown University demic. 7 The disease is also endemic in four gree of re-infection with S. japonicum in faculty members pursue active work in countries of the Western Pacific region, the ensuing 18 months. We also assessed global health in these places; this report with 600 million people at risk of infec- hepatic fibrosis at baseline and the 12 provides a summary of our current and tion with S. japonicum. 8 Movement of month follow-up using portable ultra- recent research and future directions. populations and anthropogenic environ- sound. At the 18 month follow-up all mental changes that result from water re- subjects were re-treated for schistosomiasis SCHISTOSOMIASIS IN THE source development will facilitate the emer- and helminth infections identified dur- PHILIPPINES gence and resurgence of schistosomiasis in ing the study. Together with the Research Institute areas currently with low endemnicity. In order to quantify the relationship of Tropical Medicine in Manila, a unit of The contribution of schistosomiasis to between S. japonicum and cognitive im- the Philippine government Department morbidity and mortality has recently been pairment we conducted a cross-sectional of Health, investigators based at the Brown reassessed using reported symptoms, and analysis at baseline among those 7-18 University International Health Institute available and predicted prevalence of in- years. 10 Learning and memory cognitive and Lifespan’s Center for International fection data. Such data estimate global domains were each defined by three sub- Health Research have been investigating deaths to be as high as 200,000 per year scales of the Wide Range Assessment of schistosomiasis for over two decades. In in comparison with earlier estimates of Memory and Learning (WRAML) and fact several Brown University faculty fea- 11,000-15000. 8 This recent calculus also logistic regression models estimated asso- tured their research in a 1992 issue of this found disability estimates between 4-30 ciations between performance in differ- journal dedicated to schistosomiasis. 3 In times greater than the 1996 Global Bur- ent cognitive domains (learning, memory, this article, we will first provide an over- den of Disease analysis. 9 This has placed and verbal fluency) and helminth infec- view of schistosomiasis, then focus on stud- schistosomiasis as the third most significant tions. After adjusting for age, gender, ies conducted in the past decade, and fi- tropical disease in the Tropical Disease nutritional status, hemoglobin, and SES, nally discuss future goals and directions. Research portfolio, following malaria and S. japonicum infection was associated with Schistosomiasis infection affects ap- intestinal helminthiases. Of note, the dis- poor performance on tests of learning proximately 207 million people in tropical ability estimate does not include the im- (OR = 3.04; 95%CI= 1.1 – 6.9), A. countries, 20 million of whom have severe pact of schistosomiasis on pregnancy. lumbricoides infection was associated with illness. 4-6 Individuals are infected when they poor performance on tests of memory wade into fresh water and cercaraie pen- MORBIDITY FROM S. JAPONICUM (OR = 2.2; 95%CI= 1.04 – 4.7) and T. etrate the skin to begin the human portion INFECTION IN THE PHILIPPINES trichiura infection was associated with of the life cycle. Three main species infect Studies conducted in three S. poor performance on tests of verbal flu- humans. S. japonicum and S. mansoni adult japonicum-endemic rice-farming villages ency (OR = 4.5; 95%CI= 1.04 – 30). worms live in the mesenteric veins. Pathol- in Leyte, The Philippines, were designed The association between S. japonicum ogy is mainly due to eggs that are swept up to identify vaccine candidates for S. and learning was of interest as learning 346 MEDICINE & HEALTH/RHODE ISLAND had not yet been studied in this context tus after adjusting for age, gender, other tion was associated with decreased serum and may reflect the potential to take ad- helminths, and SES. After controlling for albumin levels, (HAZ), and BMIZ (all vantage of limited educational opportu- confounders, intensity of S. japonicum in- P<0.05). 16 Re-infection was associated nities in lesser developed countries fection was inversely related to HAZ with decreased albumin (P<0.0001). S. (LDCs). We were also surprised to find among children <= 12 years (P = 0.03), japonicum infection and reinfection were that this relationship was maintained but not to BMIZ (P = 0.52) Adjustment positively associated with both serum even after adjusting for hemoglobin, a for SES allowed a more accurate assess- CRP and IL-6 production. CRP, in turn, proxy here for iron status. This suggests ment of the relationship between S. was inversely associated with BMIZ and that S. japonicum may affect cognitive japonicum and PEM than was possible in albumin (all P<0.01). This suggests that processes through mechanisms other previous studies. In addition, we used our inflammation in general and pro-inflam- than inadequate iron supply for central longitudinal data to assess whether chil- matory cytokines in particular mediate S. nervous system functions. Other mecha- dren experienced improved growth and japonicum-associated undernutrition. nisms may include distraction from tasks PEM following treatment for S. A major unanswered question in based on symptomatology or the effect japonicum.14 HAZ and BMIZ improved schistosome research is: Why are children of pro-inflammatory cytokines on CNS modestly but significantly over time fol- more susceptible to both infection with S. functions, which cause inattention, a lowing treatment. BMIZ in children nu- japonicum and disease due to infection? phenomenon seen during acute illnesses tritionally wasted at baseline improved the Because the dramatic changes in suscepti- known as “sickness behavior.” most (0.41 [0.26-0.56] Z-score unit) and bility to infection and disease occur dur- Two other studies were conducted HAZ improved only in children stunted ing adolescence, we assessed the role of to determine the etiology of anemia in at baseline (0.17 [0.l2-0.21] Z-score unit). pubertal development in modulating re- the context of S. japonicum. Using both High intensity re-infection at 18 months sistance to infection 17 and disease. 18 In cross-sectional 11 and longitudinal 12 data was associated with significantly less abso- cross-sectional analyses, the intensity of from this cohort, we found that the pre- lute growth from baseline compared to infection among individuals with high dominant cause of S. japonicum-associ- lower intensity and no re-infection. Based DHEA-S levels (a measure of adrenarchy) ated anemia is anemia of inflammation, on these findings, we recommend that was 43% lower (28 eggs per gr, n=243), also known as anemia of chronic disease. children be treated at least annually to compared with individuals with low Anemia in the setting of acute/chronic avoid these morbidities. DHEA-S levels (50 eggs per gr, n =243), inflammation is mediated by: 1) de- We were also interested in the even after adjusting for age, sex, and vil- creased erythropoietin production and/ mechanisms mediating altered growth lage (P = 0.01 ). Following praziquantel or responsiveness of erythrocyte precur- and PEM in the context of S. japonicum. treatment, increased DHEA-S levels were sors in the bone marrow, 2) decreased Using our cross-sectional data, we exam- associated with resistance to re-infection erythrocyte lifespan, and 3) shunting of ined the relationship between growth (P = 0.006). The intensity of re-infection bio-available iron to storage forms and stunting and PEM and grade of hepatic among individuals with high DHEA-S possibly reduced uptake of dietary iron fibrosis among subjects. 15 Hepatic fibrosis levels was 42% lower, compared with in- in the gut. Thus, though individuals may was present in 8.9% of the cohort, the dividuals with low DHEA-S levels, even be iron replete, this iron is not usable by majority of which consisted of grade I fi- after adjusting for age, baseline intensity the bone marrow and other tissues and brosis. Only males had moderate or se- of S. japonicum infection, village, sex and anemia ensues. Blood loss in stool likely vere fibrosis (grade II or III; n = 10). water contact (P < 0.001). plays a role only at higher intensities of Compared to subjects without fibrosis, These data suggest that an intrinsic infection. Importantly, anemia of inflam- individuals with mild (grade I) and, even property of host pubertal development mation is the predominant cause among more so, severe fibrosis had significantly mediates, in part, the resistance to infec- individuals with low or moderate inten- lower BMI z-scores, a higher prevalence tion observed in older individuals. sity infections, by far the most common of anemia, higher levels of C reactive pro- Because pubertal development is as- intensities of infection. This suggests that tein (CRP) and greater IL-6 production. sociated with a down-modulation of pro- anemia is unlikely to be ameliorated by Furthermore, severely fibrosed individu- inflammatory responses, we hypothesized iron therapy alone. Rather, an approach als had significantly higher levels of IL-1 that pubertal development may predict whereby S. japonicum is treated and iron compared to those with no or mild fibro- improved nutritional status independent of therapy is instituted is necessary. sis. These findings suggest that even mild chronic parasite infections. 18 In cross-sec- In addition, we sought to quantify fibrosis is associated with nutritional mor- tional multilevel linear and logistic regres- the effect of S. japonicum on childhood bidity and underscore the importance of sion analyses, adjusted for confounders, re- growth and protein-energy nutritional early recognition and treatment of he- lationships were assessed between 1) status (PEM). Using cross sectional data, patic fibrosis. In addition, our data are DHEAS and nutritional status, 2) DHEAS we examined the relationship between consistent with the hypothesis that he- and proinflammatory cytokines, and 3) height-for-age Z-score (HAZ) and body- patic fibrosis causes undernutrition and nutritional status and proinflammatory mass-index Z-score (BMIZ) and S. anemia by systemically increasing levels cytokines. Independent of age, SES and japonicum.13 Multivariate models were of the proinflammatory cytokines IL-1 helminth infections, increased levels of created to assess the relationship between and IL-6. Finally, using our longitudinal DHEAS were associated with improved S. japonicum infection and nutritional sta- data, we found that S. japonicum infec- nutritional status and decreased prevalence 347 VOLUME 90 NO. 11 NOVEMBER 2007 of non-iron deficiency anemia in both weights assigned to the various specific The adjusted prevalences of humans males and females. DHEAS showed a dose- sequelae of infection. 20 The estimated S. lightly, and at least moderately infected, dependent inverse relationship with CRP japonicum disability weights were seven varied across villages from 0% (0-3.1%) and production of IL-6 (P=0.08 and to 46 times greater than current GBD to 45.2% (36.5-53.9%), and 0% to <0.0001, respectively). These inflammatory measures for all schistosomiasis. 8, 9 In the 23.0% (16.4-31.2%), respectively. Inter- markers, in turn, were consistently associ- future we plan to study actual reported village variation in prevalence is large. 21 ated with undernutrition and anemia. disability among infected and uninfected The adjusted overall prevalences for These results suggest that the puberty-as- children and adults in a large commu- dogs, cats, pigs, water buffaloes, and rats sociated rise in DHEAS downmodulates nity study in order to provide another were 15.4% (95% BCI:12.6-18.6%), proinflammatory immune responses and independent line of evidence for estimat- 2.6% (1.5-4.1%), 2.0% (1.2-3.3%), thereby reduces undernutrition and ane- ing the human burden of S. japonicum 2.1% (1.3-3.3%), and 32.6% (28.0- mia in a population experiencing a high infection. 37.4%), respectively. 23 The adjusted burden of chronic helminth infections. This prevalence for all animals varied substan- novel regulatory mechanism of inflamma- ECOLOGY AND TRANSMISSION OF S. tially across villages. Human infection was tion-related nutritional morbidity empha- JAPONICUM IN THE PHILIPPINES highest in males 17-40 years and females sizes the importance of treating pre-pubes- Coincident with studies of immunity 11-16 years. 21, 22 People who worked full- cent children for helminth infections. and morbidity we conducted interdisci- time on a rice farm had higher prevalence A major goal of our studies was to plinary large scale epidemiologic and eco- of infection than those not working on a determine the relationship between im- logical studies of S. japonicum transmis- rice farm. The villages’ irrigation had no mune responses to several vaccine candi- sion in 50 villages on Samar island, north effect on human infection prevalence. 22 dates and resistance to re-infecion. 19 In of Leyte. The overall objective was to de- In one of our most exciting findings, longitudinal analyses a Th2 bias in re- velop a generalizable predictive ecologi- we estimated that baseline intensity of in- sponse to Sj97 (a leading vaccine candi- cal model of schistosomiasis transmission fection in dogs and cats was associated with date) predicted a 1.6- to 2.2-month to humans. The model was to include intensity of infection prevalence in hu- longer time to reinfection (P < 0.05) and several species, their population biology mans .22 The ORs of the Bayesian hierar- a 30 to 41% lower intensity of reinfec- and behavior, including humans, animal chical logit model showed that a unit in- tion (P < 0.05). These findings under- reservoir hosts and snails. The emphasis crease in the village-level mean eggs per score Th2-type immune responses as cen- was on the potential role of irrigation for gram (epg) in dogs, cats, pigs and rats, in tral in human resistance to S. japonicum rice farming and non-human animals on univariate analyses, were 1.1 (1.0-1.1), 1.4 and support Sj97 as a leading vaccine transmission. Using the transmission (1.0-1.8), 1.2 (0.2-5.2) and 1.0 (1.0-1.0), candidate for this parasite. model, expansion of irrigation, develop- respectively. The association between cat ment of water catchments, and interven- and dog epg and human infection may FUTURE DIRECTIONS OF tions on snails and non-human animals explain in part why S. japonicum is still MORBIDITY RESEARCH can be evaluated formally. endemic in areas of the Philippines after Schistosome infection leads to a wide In order to obtain a large representa- implementing human infection control range of overt and subtle morbidities and tive sample, care was taken in selecting the programs. Water buffaloes do not appear these morbidities are largely due to the 50 villages, census of humans and animals, to play an important role in the epidemi- host’s pro-inflammatory response to para- and selection of households and study par- ology of human infection in the Philip- site antigens. In pilot work, we determined ticipants, snail sites, and other mammalian pines, unlike in China that S. japonicum is associated with poor hosts. 21-23 We tried to collect three stools Further work will explore if addi- pregnancy outcomes and this may be me- from all humans and all animals over con- tional ecological differences exist between diated by pro-inflammatory placental in- secutive days, and established an accurate the regions; such as micro-spatial pat- jury and deranged maternal iron metabo- measure of animal infection. 24 Those with terning of water flows, snail colonies, lism. To further assess this potential mor- at least one stool sample were included in human behaviors and rice farms influ- bidity, we are conducting a randomized analysis. At baseline, we studied 5623 ence transmission. Finally, development controlled trial to assess the impact of humans, 1189 dogs, 1275 cats, 1899 pigs, of fully specified transmission models Praziquantel treatment of schistosome-in- 873 water buffaloes, 663 rats and 730 seems especially crucial given the diffi- fected mothers on birth outcomes. In ad- potential snail sites in 25 irrigated villages culties in community adherence to mass dition, our immunology studies have im- and 25 rain-fed villages. After baseline, chemotherapy for a low mortality disease plicated Sj97 as a leading vaccine candi- PZQ treatment was available for all vil- and the long time horizon for anti- date for S. japonicum. We are developing lage residents, not only study participants. schistisomiasis vaccines. Such models may method for the recombinant expression The 12-month follow-up assessed re-in- help us make the most cost-effective de- and purification of Sj97 under GMP con- fection in study participants, sampled at cisions about interrupting transmission of ditions in preparation for pre-clinical and random another 35 animals of each spe- infection at different ecological levels Phase I vaccine trials. cies in each village and revisited all po- from snails, water systems, rice farms, to We are finishing an analysis to esti- tential snail sites to determine ecological, animal and human fecal disposal and mate the burden of disease from S. animal and snail predictors of human re- water contact. japonicum by revising the disability infection. 348 MEDICINE & HEALTH/RHODE ISLAND NON-COMMUNICABLE DISEASES IN period. By 2003 almost 30% of the men lence in all sex and age groups. For ex- THE SAMOAN ISLANDS and more than 50% of women in Samoa ample, prevalence was 2.4% in men 25- The Samoan islands are located half- were classified as obese.27, 28 Levels of 54 years in 1991 but 6.0% in 2003. way between Hawaii and New Zealand. overweight and obesity among adults in Likewise in women, prevalence rose from Since the end of World War II, the Sa- American Samoa in the 1970s match the 3.0% to 8.2% in those 25-54 years. In moan islands have rapidly changed and levels in Samoa thirty years later. 2003 when a wider age range was modernized.25-28 Since 1975 one of us Children have also been affected. In sampled diabetes prevalence in Samoa (SMcG) has done public health research American Samoa there was a strongly in- was 9.3% and 12.6% in mean and in Samoan communities with the support creasing temporal trend in age and sex women, respectively. of the Ministry of Health of Samoa, and specific childhood BMI from 1978 to From the earliest studies through the Department of Health of American 2002. The mean BMI increased over the the present, the prevalence of elevated Samoa with an epidemiologic and bio- 24 years ranged from 1.9 to 3.8 kg/m2 blood pressure has been quite high logical anthropological focus on obesity in boys and girls 6-11 years of age. In among Samoans. 25, 28 We define hyper- and cardiovascular disease (CVD) risk adolescents 12-17 years of age, the tem- tension as a blood pressure +140/90 factors. This work has spanned the spec- poral BMI increases ranged from 3.6 to mmHg, or on anti-hypertensive medi- trum from genetic to psychosocial stress 5.8 kg/m2 in boys and 4.9 to 5.8 kg/m2 cation. Across all age groups, American studies and now includes public health in girls. Approximately 70% of boys and Samoan men had a prevalence of hyper- intervention studies on type 2 diabetes. over 80% of girls 15-17 years of age in tension of almost 40% in 1976-1978 Here we briefly summarize the impact American Samoa in 2002 are overweight and 46% in 2002. In 2002 among all of modernization or economic develop- or obese, using international BMI stan- the age groups 35 years and older more ment on temporal trends in CVD risk dards for youth.29 In girls 12-14 years of than half of the American Samoan men factors among Samoans in the less eco- age over 65% are overweight or obese. had hypertension. American Samoan nomically developed nation of Samoa and Even among the youngest American Sa- women of all ages had a hypertension the more developed US territory of moan boys and girls 6-11 years of age, prevalence of about 35% in the 1970s American Samoa. The Samoan temporal only 49% to 56% are of normal BMI. In and 31% in 2002. However, in those trends exemplify, in the extreme, the nu- Samoa, the proportion of overweight and 55-74 years at each time hypertension trition transition. obese children is quite a bit smaller than ranged from 57% to 67%. In less mod- Samoans, along with other indig- in American Samoa. ernized Samoa hypertension prevalence enous groups across the globe, have suf- Children measured in Samoa be- is not as extreme as in American Samoa, fered from sharp increases in the preva- tween 1979 and 1982 had a very low but is still quite high. In 1979-1982 in lence of obesity and chronic disease as prevalence of obesity. Between 1979 and Samoa, 17% of men and 12% of women their lifestyles have become more mod- 2003 there was a four-fold increase in the 18-74 years had hypertension. By 2003, ernized. Here we report overweight and prevalence of obesity among boys and an hypertension prevalence had increased obesity using Polynesian specific, and almost eight-fold increase in the preva- to 30% in men and 29% in women, body composition validated, standards27 lence of obesity among girls. In 2003 with the highest proportions among for BMI: overweight is a BMI of 26-32 about 77% to 86% of boys of all ages are those 55-74 years of age. kg/m2 and obesity is BMI > 32 kg/m2. of normal BMI. In girls from Samoa in The high and increasing levels of Between 1976 and 2002, BMI levels 2003, the proportions of those who are obesity and CVD risk factors over the past and prevalence of obesity continued to overweight or obese ranges from 21% to 30 years among Samoans, and now its drastically increase among American Sa- 26% in young girls but rises to 37% to appearance in children suggest that this moan men and women. By 1990 the 39% in 12-17 year olds. trend may worsen before leveling off. In percent of obese women increased to Contemporary Samoan adults have addition, the rapidly increasing preva- 70%, from 51% in 1976-78, and by not escaped obesity-related Type 2 dia- lence of obesity among children, espe- 2002 it reached 71%. In American Sa- betes. 28 The prevalence of diabetes cially those living in American Samoa, moan men, there was a dramatic increase among men 25-54 years from Ameri- suggests that the epidemic may shift to from the 1970s to 1990 in the preva- can Samoa in 1990 was 12.9%; by 2002 younger age groups. If these trends con- lence of obesity, from 28% to 61%, with prevalence in the same aged men was tinue, chronic disease will remain a ma- little additional change in these 17.2%. Over all adult ages, 18-74 years, jor determinant of health in the Samoan prevalences in 2002. While levels of over- seen in 2002 in American Samoa type islands. In the future there may be an weight and obesity in Samoa are not as 2 diabetes prevalence was 21.6% in men earlier onset of chronic disease, and con- severe as those in American Samoa, they and 18.0% in women. In women 25- sequentially a decrease in quality of life too have continued to increase since the 54 years of age from American Samoa and life expectancy. 1970s. In men, 56% in the 1970s were prevalence doubled from 8.1% in 1990 These data illustrate the immediate of normal BMI, which was reduced to to 16.7% in 2002. Diabetes prevalence need for intervention in the Samoan is- less than one third in 1991 and 2003. in Samoa was far lower at each time for lands. We have made a small start In women, the reduction in the propor- both sexes in contrast with American through a new translational research tion of normal BMI individuals was from Samoa. But from 1991 to 2003 there grant aimed to help management of type 34%, to 18% to 17% over the same time were striking increases in diabetes preva- 2 diabetes. We will use community health 349 VOLUME 90 NO. 11 NOVEMBER 2007 workers to provide outreach to patients REFERENCES Jennifer F. Friedman, MD, MPH, and their families, and will work with 1. Trowell HC, Burkitt DP, editors. Western Diseases, PhD, is Assistant Professor of Pediatrics, providers in a primary care setting to Their Emergence and Prevention. Cambridge: Warren Alpert Medical School at Brown Harvard University Press, 1981. track adherence and blood glucose con- 2. Lopez AD, et al. (2006) Lancet 2006;367, 1747- University, and Center for International trol. We also hope to conduct behavioral 57. Health Research, Lifespan. interventions among overweight Samoan 3. RI Med 1992;75(4). Jonathan D Kurtis, MD, PhD, Asso- adolescents. 4. Engels D, et al. Acta Trop 2002; 82: 139-46. ciate Professor of Pathology and Laboratory 5. Steinmann, P, et al. Lancet Infect Dis 2006;6: 411-25. 6. Chitsulo L, et al. Nat Rev Microbiol 2004;2: 12-3. Medicine, Warren Alpert Medical School CONCLUSION 7. TDR (2002) TDR Strategic Direction: Schisto- at Brown University, and Center for In- We have attempted to show the somiasis. Volume, DOI: http://www.who.int/ ternational Health Research, Lifespan. tdr/diseases/schisto/direction.htm wide range of global health research con- 8. WHO Schistosomiasis: WHO regional office for Stephen T. McGarvey, PhD, MPH, is ducted in the Asia Pacific region on both the western Pacific. 2005. Professor of Community Health and An- infectious parasitic diseases and NCD. 9. King CH, et al. Lancet 2005;365: 1561-15. thropology. Warren Alpert Medical School The dual burden of these conditions as a 10. Ezeamama AE, et al. Am J Trop Med Hyg 2005;72: at Brown University, and the International 540-8. result of the process of the health transi- 11 Kanzaria, HK, et al. Am J Trop Med Hyg Health Institute, Brown University. tion is found in both locations high- 2005;72:115-8. lighted here, as well as many other na- 12. Leenstra T, et al. Infect Immun 2006;74; 6398- Disclosure of Financial Interests tions. Despite large regions of rural pov- 407. The authors have no financial inter- 13. Friedman JF, et al. Am J Trop Med Hyg 2005;72: erty and parasitic infections The Philip- 527-33. ests to disclose. pines is also experiencing a rapid rise in 14. Coutinho HM, et al. J Nutr 2006;136: 183-8. CVD risk factors. 30 Likewise, infectious 15. Coutinho HM, et al. J Infect Dis 2005;192:528-36. CORRESPONDENCE parasitic diseases exert a morbidity bur- 16. Coutinho HM, et al. Am J Trop Med Hyg 2006;75: Jennifer F. Friedman, MD, MPH 31 720-6. den in the Samoas. 17. Kurtis, J.D, et al. Clin Infect Dis 2006;42: 1692-8. Center for International Health Our aim is to continue to perform 18. Coutinho H, et al. (In Press) DHEAS predicts Research interdisciplinary biomedical and public improved nutritional status in helminth infected 55 Claverick St., Suite 101 health research on infectious diseases and children, adolescents and young adults in Leyte, Providence, RI 02903 the Philippines. J Nutr NCD in The Philippines and the Samoan 19. Leenstra, T, et al. Infect Immun 2006;74, 370- Phone: 444-7449 polities. This fundamental research will 81. e-mail: [email protected] allow us to conduct translational and 20. Finkelstein JL, et al. Am J Trop Med Hyg 2005;73:341. policy-oriented research which can di- 21. Tarafder MR, et al. BMC PublicHealth 2006;6: rectly inform best clinical and preventive 61-5. practices. Meanwhile, we are acutely 22. McGarvey ST, et al. Bull WHO 2006;84: 446- aware that the distribution of resources 52. 23. Tarafder MR. et al. (2007) Prevalence of Schisto- during the globalization process may not soma japonicum infection among animals in 50 equally benefit all study populations. We villages of Samar Province, The Philippines.Vector- hope that our research will contribute to Borne & Zoonotic Diseases 2007. (In press). fundamental progress in knowledge 24. Carabin H, et al. Int J Para 2005 ;35 : 1517-24. 25. McGarvey ST, Baker PT. Human Biol about these diseases but also to sustain- 1979;l51:461-79. able improvements in population health 26. McGarvey ST. Am J Clin Nutr. 1991;53, and material ways of life in these com- 1586S-94S. munities. 27. Keighley ED, et al (2006) Farming and Adipos- ity in Samoan Adults. Am J Hum Biol 18, 112- 121. 28. Keighley, ED, et al. Nutrition and health in modernizing Samoans. In R Ohtsuka, SJ Ulijaszek (eds). Nutrition and Health Changes in the Asia- Pacific Region: Biocultural and Epidemiological Approaches. Cambridge University Press: Cam- bridge, UK, 2007:141-91. 29. Cole TJ, et al. BMJ 2006;320:1240-3. 30. Reyes-Gibby CC, Aday,LA. J Community Health. 2000;25, 389-99. 31. Urbani C, Palmer K. Trop Med Int Health 2001;6:935-44.

350 MEDICINE & HEALTH/RHODE ISLAND Perspectives from Brown Medical Students and a Medical Resident The Warren Alpert Medical School in the Dominican Republic David Sears, MD He was a young man, perhaps 23 or 24, certainly no older Under the leadership of Mark Fagan, MD, of Rhode Island than I. It must have been 90 degrees in the emergency Hospital and Joe Diaz, MD, of Memorial Hospital, the exchange room that evening, and he was sweating. He was sitting program that I joined in early 2005 has expanded while maintain- bolt upright on the gurney with his hands gripping the side ing its strong ties with Cabral y Baez, the hospital in Santiago. We railing. His neck was rigid and extended toward the ceil- now also see outpatients at a free rural clinic called Pequeños Pasitos, ing, meaning he had to look downward to see me. He was established by a Dominican-American couple. Participants from breathing heavily through clenched teeth. He looked afraid. Brown, including residents and physicians from the Department of A deadly tetanus toxin was coursing through his blood. Family Medicine at Memorial Hospital, bring medical supplies to the clinic, see patients with the Dominican doctor on staff, and work It was February 2005 when I saw this patient in the emer- on public health projects. The exchange program is also integrated gency room at Hospital José María Cabral y Baez in Santiago. I was with tropical medicine and medical Spanish curricula to further a third-year medical student, spending a month in the Dominican develop language and clinical skills that are invaluable both in the Republic with a group of classmates, internal medicine residents, Dominican Republic and upon our return to Rhode Island. To and attendings from Brown Medical School. A four-hour flight ensure that the benefits of the program do not flow in one direction separates Santiago from the major cities of New England, but this only, internal medicine residents from Santiago rotate through the large public hospital might as well have been in another world. Dis- Brown hospitals to learn from our health care system. ease was rampant; patients had to pay for most diagnostic tests and In addition to the exchange program, Brown lends vital sup- treatments before they could receive them, and the minimal labora- port to the large outpatient HIV clinic at Cabral y Baez. The HIV tory and imaging modalities were unreliable. pandemic has ravaged the Caribbean: an estimated 1.1% of adults Over the next few weeks our group attended didactic confer- in the Dominican Republic are infected with HIV2 and less than ences in the hospital, worked with physicians in the outpatient HIV 20% of those in need of antiretroviral therapy are receiving it.3 In clinic, went on rounds, and evaluated new patients in the emer- efforts spearheaded by Michael Stein, MD, of Rhode Island Hospi- gency room. We saw an enormous array of pathology, from infec- tal, Brown has greatly improved the quality and quantity of HIV tious disease staples like dengue, malaria, leptospirosis, and advanced care in Santiago. We hired an excellent Dominican physician to HIV, to a range of zebras such as relapsing polychondritis, Ludwig’s work alongside the two physicians who were volunteering in the angina, and neurofibromatosis. More importantly, we experienced clinic but could not keep up with the influx of new patients. We a health care environment that is vastly different from our own, and organized the donation of computers to the clinic, which enabled we saw the challenges that this system created for the men and women the implementation of an electronic medical record-keeping sys- providing medical care and the patients who sought their services. tem. The electronic records allow Dr. Stein to lend medical exper- When I returned to Rhode Island, to what suddenly seemed tise in the management of difficult cases. In addition, we have sup- like the very comfortable life of a medical student, I had a hard ported the education of adherence and prevention counselors and time letting go of the things I had seen and the people I had met organized the donation of thousands of condoms and medications. on my brief trip. By the end of the year I found myself in Santiago Through the efforts of volunteer physicians and students we have again, this time for a nine-month period that I spent developing improved the care of thousands of patients in places like Pequeños Brown Medical School’s service projects in the country. These Pasitos, the inpatient wards in Cabral y Baez, and the outpatient HIV projects include a medical exchange program and an HIV treat- clinic. The more lasting effects of these initiatives, however, will be in ment and prevention initiative. Our focus is to provide valuable the foundation that these programs lay for the training of Dominican services to the neediest patients and to teach and learn from our and American students and medical residents. While it is important Dominican colleagues in ways that greatly benefit our mutual to return from the Dominican Republic with a better understanding growth as physicians. Basing this program in the heart of the of diseases like cerebral malaria and dengue, it is even more important Dominican Republic also has a number of benefits for our work to return with a renewed sense of social consciousness and purpose. back home; 10.3% of Rhode Island’s population is Latino or His- Often this comes at a time when program participants are making panic (including 30% of Providence residents) and a large pro- decisions that will define their medical careers. I know this because I portion of this population is of Dominican origin.1 Furthermore, am one of those people, and I am certain that as I navigate down my the rise in the Dominican middle class means that more people career path, the memories of the people I worked with and the pa- are traveling between the two countries. Quality medical care tients I was fortunate to know will guide my decisions. requires not only an understanding of the wide breadth of ill- The young patient with tetanus whom I encountered in the nesses seen in this immigrant community, but also competence in ER that evening died on his third day in the hospital. His death, the cultural, linguistic, and social context of those illnesses. so easily preventable, represents a failure of so many societal, po- 351 VOLUME 90 NO. 11 NOVEMBER 2007 litical, and economic systems that the geographic barriers dividing us become inconsequential, and we should all feel responsible for REFERENCES his passing. It is patients like him—or the thousands of Domini- 1. US Census Bureau. Rhode Island Quick Facts. Accessed from http:// cans who still need antiretroviral medications, or the legions of quickfacts.census.gov/qfd/states/44000.html on 12/18/2006. 2,UNAIDS. 2006 Report on the Global AIDS Epidemic: A 10th Anniversary pregnant women and elderly farmers waiting for appointments at Special Edition. Geneva, Switzerland. Pequeños Pasitos—who remind us of the work that needs to be 3. UNAIDS. 2006 Caribbean Fact Sheet. Geneva, Switzerland. done. The commitment of the Brown community to the pro- grams in the Dominican Republic has been substantial, and the David Sears, MD, BMS ’97, is an internal medicine resi- progress made has been impressive, but satisfaction with our dent at Columbia University. achievements will not solve the health problems that plague the populations we serve. A further investment of resources—both Disclosure of Financial Interests human and financial—is needed. These resources must go to- The author has no financial interests to disclose. ward caring for patients now, but they must also be invested in the development of generations of like-minded health care profes- CORRESPONDENCE: sionals, both Dominican and American, who will carry on the David Sears, MD tradition of service to our deeply intertwined communities. e-mail: [email protected] Going Home: Lessons for a Brown Medical Student in Cambodia E. John Ly, BMS IV

For many reasons, my first visit to Cambodia—one of the poorest ease burden, in hopes of providing evidence to support the rou- countries in Southeast Asia—was the richest experience in my life. tine administration of Hib conjugate vaccines in Cambodia. In the summer of 2005, with the support of a scholarship from the While Hib vaccines have been in use in the US and other Infectious Disease Society of America, a Foreign Studies Fellowship developed countries for over a decade and have dramatically from Brown University’s International Health Institute as well as reduced the rate of Hib disease—most notably meningitis, contributions from family and friends, I worked on a project at epiglotottis and pneumonia—Hib vaccines are not widely used Angkor Hospital for Children (AHC) in Siem Reap, Cambodia. in developing countries. The prohibitive factor has been the AHC is a non-profit hospital that opened in 1999 with the cost. Currently, Hib vaccines cost around US$7 per child for support of internationally-acclaimed Japanese photographer the recommended three doses, roughly seven times the total cost Kenro Izu and his New York City-based fundraising branch, of vaccines against measles, polio, tuberculosis, diphtheria, teta- Friends Without a Border. Since its inception, the hospital has nus, and pertussis.3 While it is most likely cost-effective to make provided free healthcare to mostly poor, rural children in north- Hib vaccines available to developing countries, efforts to dem- west Cambodia. To date, it is staffed predominantly by local onstrate Hib disease burden have been inadequate, and that has Cambodians, serves as one of the only pediatric teaching hospi- been a barrier to introducing vaccine programs. tals in the country and has provided care for over 400,000 chil- As a testament to the fractured state of healthcare in Cambo- dren.3 Recently, it developed a strong relationship with the dia, we could not proceed with our original study design because Warren Alpert Medical School and has been a site of active ex- many patients admitted for pneumonia had already received some change of medical personnel at all levels of training. antibiotics and blood cultures would be less effective in detecting This trip was especially meaningful to me because I was re- any pathogens. These patients were getting antibiotics from a vari- turning to the country that my parents left as refugees 25 years ety of sources—regional health clinics, private pharmacies and mar- earlier. Ostensibly, I left to carry out research related to pneumo- ketplaces—before presenting to AHC. There is no system of pre- nia; but in the process, I returned having learned lifelong lessons scriptions in Cambodia. The majority of patients bought antibiot- about health, development, and myself. As a novice, I stumbled through the usual obstacles of working abroad: getting IRB ap- proval, finding funding, setting up the logistics of the project and adjusting plans as needed. But I knew the difficulties of my jour- ney to Cambodia, however frustrating, paled in comparison to those of my parents’ journey to the US; their harrowing voyage involved a 200-mile trek through dense forests, a protracted stay at a Thai refugee camp, and a plane ride to a country whose lan- guage and culture were completely foreign to them. With the help of my advisor, Dr. David Pugatch, and col- leagues at AHC, I developed a project based on one of the needs that had been expressed. The initial plan was to carry out a blood culture study to determine the causative organisms in bacterial pneumonia among patients at AHC. One of the focuses was to Each day, hundreds of patients get processed through triage at elucidate the rate of Haemophilus influenzae type b (Hib) dis- Angkor Hospital for Children. (photographer: Daniel Rothenberg) 352 MEDICINE & HEALTH/RHODE ISLAND 315 VOLUME 90 NO. 10 OCTOBER 2007 316 MEDICINE & HEALTH/RHODE ISLAND 317 VOLUME 90 NO. 10 OCTOBER 2007 ics from outdoor marketplaces, often from untrained store keepers. While the government had set up regional health centers, the government had not invested money in staffing the clinics. The doctors and nurses who staffed these facilities were paid $20 a month - less than the median annual income of $300.3 In order to support their families, many of the clinic staff took second jobs, with some opening pharmacies in outdoor marketplaces. Therefore, govern- ment clinics were regularly understaffed. Workers would come in late, irregularly, or not at all. Local residents did not rely on these clinics and instead went to the marketplace pharmacies for drugs before being seen by a healthcare worker. This failure in the system was not isolated. There seemed to be an underinvestment in education as well and these problems A resident examines a patient in the inpatient department at contributed to the stark inequities that were readily visible: shiny Angkor Hospital for Children. (photographer: Daniel Rothenberg) Land Cruisers shared the road with ox-carts; five-star hotels filled Cambodia appears to be slowly recovering from the starvation of its with well-healed tourists were down the street from make-shift war and genocide. And as with all developing countries, Cambodia’s shacks crowded with out-of-town squatters looking for work. future success depends on the world’s commitment to ensuring a Whether on the streets or in the hospital, I found many things basic level of opportunity that includes adequate health. discouraging. On daily afternoon rounds at the hospital, we came Work continues at AHC; and like the numerous people who across many sick patients. Children were afflicted with end-stage have volunteered there, I plan to return. While I try to contribute AIDS, rheumatic heart disease, miliary tuberculosis and acetami- I know that, through the relationships formed and the lessons nophen toxicity, among other illnesses. Many of their diseases learned, I have received much more than I could ever give. were preventable or would be treatable in the developed world. This was especially difficult for me to consider, since I felt a strong REFERENCES connection to the children there. Besides luck and circumstance, 1. Friend Without a Border. www.fwab.org. Accessed Dec 21, 2006. I saw little difference between myself and them. Where I had 2. World Health Organization. Hib Media Center. http://www.who.int/ mediacentre/factsheets/fs294/en/index.html. Accessed Dec 21, 2006. been given a wealth of education and the fortune of health, they— 3. CIA World Factbook. https://www.cia.gov/cia/publications/factbook/geos/ victims of poverty and injustice—lay sick or dying. cb.html. Accessed Dec 21, 2006 Despite the multitude of dispiriting realities, there was much to be hopeful for even if it was moving at a sluggish pace. This was Disclosure of Financial Interests. perhaps best exemplified on our visits to the re-feeding ward, where The author has no financial interests to disclose. our afternoon rounds finished each day. Children who had pre- sented with severe malnutrition were being re-fed carefully, with CORRESPONDENCE: small increases in their caloric intake, to prevent re-feeding syndrome. E. John Ly Though slowly, they were surely getting better. Like these children, e-mail: [email protected]

“Village Health Works” in Burundi Natasha Rybak, MD As a fourth year medical student and the medical student leading cause of death in Burundi, is estimated to account for representative of the newly formed Internationalization Com- greater than 50% of people seeking medical care. 3 Burundi has a mittee within Brown University, I have been amazed at the total of 156 practicing physicians, More than half work in the dedication and involvement of many faculty and students in capital, where only 8.4% of the population resides.3 For rural international health. As the Internationalization Committee Burundians, access to proper healthcare is sometimes nonexistent. strives to accentuate Brown’s international strengths, it also is I spent the summer of 2006 in Burundi on a Foreign Stud- working towards creating initiatives to improve Brown’s future ies Fellowship from Brown University’s International Health In- role in an array of international realms. stitute. I was based in Rumonge, Burundi, located on Lake Burundi is a small country in East Africa with a population of Tanganyika, a region severely affected by malaria, in addition over 7 million people. It shares much of the cultural and ethnic to yearly epidemics of cholera and constant parasitic infections. history of its neighbor Rwanda. Following years of civil strife and My friend, Deogratias Niyizonkiza, now an American citizen, genocide, Burundi is struggling to support its people. With the grew up in Burundi. He talked often about his home country. violence of the 1990s largely behind it, Burundi’s mortality fig- He encouraged a group of people to come to Burundi, each ures are still among the worst in the world. The average life ex- with different talents including several medical students, an Emer- pectancy is 39 years. In March, 2005, the United Nations re- gency Department physician, an architect, a journalist, and a ported that one out of every five people in Burundi dies from literary agent. Deogratias detailed the tremendous needs and water-born diseases and poor sanitation. Malnutrition rates for his desire to create a health clinic to provide high quality medi- children under 5 were reported to be 56% in 2000.3 Malaria, the cal care to patients. He mentioned that they lacked microscopes 356 MEDICINE & HEALTH/RHODE ISLAND to diagnose malaria and that he had collected some microscopes ence the work that goes into creating sustainable, quality health for use there. Interested in going to Burundi and in finding a clinics and saw this as a vision for the village of Kigutu. way to help, I started reading about the diagnosis of malaria. When we first arrived in Kigutu, we could feel the excite- I decided to create a project to bring diagnostic equipment ment of the villagers kilometers before we reached our destina- to Rumonge for the diagnosis of malaria. The aim of this project tion. Children ran to the road and followed our vehicle, laugh- was to implement standardized microscopic diagnosis of malaria ing, delighted by our waves. As we pulled into the field we in Rumonge Hospital while evaluating and comparing it to clini- were immediately surrounded by hundreds of villagers, eager cal diagnosis. In preparation for my trip, I applied for and re- to show us the pile of bricks and stones they had collected for ceived $850 of funding from the Dean’s Independent Scholars the foundation of their long awaited health clinic. Fund to pay for the additional microscopic supplies. Spending As our small group spent more time in Burundi, the plans time with my parisitologist professor, I carefully examined slides for an expandable model health clinic in Kigutu unfolded. Af- that had been vigilantly stored for years as the last surviving ma- ter a night of brainstorming, the name “Village Health Works” laria specimens in the school. I also visited the Rhode Island was created and the organization officially began. The vision of Hospital patient laboratory and practiced creating the perfect Village Health Works (VHW) is based on the principle that all “feathery” edge on the slide for my thin blood smear. people—including the most oppressed and impoverished— Yet none of this prepared me for the Rumonge Hospital. are entitled to the highest standards of health care in their pur- Working internationally is most of all a lesson in flexibility and suit of happy and productive lives. Working with the Kigutu patience. Upon arriving, I realized that the conditions of the community is the most important principle of the organization hospital had changed rapidly. Clinical diagnosis was no longer and integrating community members into every phase of VHW the predominant method of malarial diagnosis, because they projects will serve to create a lasting partnership that will be had recently received one microscope and had instituted mi- crucial in helping people improve their own health and lives. croscopic diagnosis as the sole method of diagnosis. Other Village Health Works hopes to initiate and strengthen health changes included a new government program to provide medi- care facilities, in addition to securing clean water and safe food, cal treatment free of charge to all children under 5 years old. basic education and economic opportunity. This was a very important step in improving health care, but Armed with the knowledge of barriers to care, we hope to fraught with difficulties as the hospitals filled up and medica- improve health care for the people of the Kigutu region by tions and staff were quickly exhausted. eliminating these barriers and inspiring hope in a population Recognizing that my proposed project would not work, I devastated by trauma. Hope can sometimes be one of the best discussed with medical staff in Burundi and fellow colleagues contributions to health. ways to utilize my time in Rumonge wisely, without hindering Upon our return from Burundi, our small group, with the the busy staff at the hospital. I decided to evaluate the barriers help and support of many close and dedicated friends, includ- to good health in Burundi and spent most of my days round- ing Partners in Health, worked together to make Village Health ing with nurses and a fellow Brown medical student and an Works live up to its name. In a few months, from August to ED physician from NYC. Working with Deogratias November, Village Health Works became a not-for profit Niyizonkiza, we knew that to create a health clinic in Burundi 501(c)3 organization and raised over $400,000. This money we would have to learn about the diseases and barriers to care. was used to finish the first clinic building, construct two more The lessons we learned in the hospital were invaluable. clinic buildings, and provide medications and equipment. In We saw patients with severe diabetes who could not afford in- the summer of 2007, one physician and 2 nurses, chosen by the sulin, and patients suffering from malaria, intestinal parasites, Minister of Health of Burundi, traveled to the Partners in Health and pneumonia. A woman suffering from eclampsia was taken site in Rwanda and were trained for patient care. in a taxi by her family to the capital because nothing could be Current plans are to begin seeing patients in November done for her in the Rumonge Hospital. Many pregnant women 2007. were hospitalized for severe malaria and several gave birth pre- If you are interested in learning more about Village Health maturely. No mother-to-child transmission of HIV prevention Works please visit our website at http://www.villagehealthworks.org was in place in the Obstetrics clinic. We learned about the or contact Natasha Rybak at [email protected]. processes that bring patients to the hospital, the trends, de- We need your support! Look for upcoming events with pending on age and financial status. We visited other hospi- Village Health Works in the Providence area! tals, including a private hospital, and saw the differences in care and patient demographics. Some patients walked miles Disclosure of Financial Interests just to come to the hospital. Other patients never came to the The author has no financial interests to disclose. hospital, avoiding it for its high fees and instead preferring to go to the local pharmacy and buy the medications they felt Natasha Rybak, MD, BMS ‘07 is a resident in Medicine/ most likely to cure them. Often these medications partially Pediatrics at Hasbro Children’s Hospital. treated their infections or masked signs of serious illness. We spent time in the village of Kigutu, near Rumonge, CORRESPONDENCE which is situated among several hills near Lake Tanganyika. Natasha Rybak, MD Deogratias, who had spent several years working for Partners e-mail: [email protected] in Health in Haiti and Rwanda, knew from firsthand experi- 357 VOLUME 90 NO. 11 NOVEMBER 2007 Brown In Kenya Edward J. Wing, MD

We landed in Nairobi, Kenya, at 10 o’clock broad vistas of savannah, valleys, tradi- The experience changed my percep- at night after an 18-hour flight from tional villages and wild animals. We ar- tion of medicine and made me acutely Boston. My fellow travelers were Jane rived in Eldoret, a city the size of Provi- aware of the needs in the rest of the world Carter, a pulmonologist in private prac- dence, in the afternoon. The next day I and the wealth of the USA. As a result, tice and a former Brown medical student. rounded on the wards, on approximately along with many members of the faculty The airport appeared old and dark, the 40 patients, with Kenyan and Brown of the Department of Medicine includ- air hot and humid Our bags were lost - medical students. Chest x-rays showed ing residents, students, and fellows, we it took us more than two hours to report the ravages of HIV, tuberculosis and have developed a number of programs them missing. The remaining part of the pneumonia. One out of 10 patients throughout the world. The programs, night was spent under mosquito netting died every day. The need was overwhelm- their directors, and contact numbers are in a hotel. The next day we traveled ing. A young patient of mine died of pre- listed below. I invite interested physicians northwest, across the equator through ventable complications of tuberculosis and students to risk having the same ad- what seemed like a primal land, with meningitis one day after I left. venture that I did, and to have a life-al- tering, wonderfully enriching experi- phone ence. Kenya: Eldoret - Exchange, Research Jane Carter 793-2431 Edward Wing, MD, is Chair, De- Janet O’Connell 793-2056 partment of Medicine, The Warren Alpert Medical School of Brown University. Dominican Republic: Santiago - Exchange Mark Fagan 444-5344 Disclosure of Financial Interests Joe Diaz 729-3400 The author has no financial inter- Michael Stein 444-8732 ests to disclose. India: Chennai, Pune - Fogarty, Research Ken Mayer 793-4710 Tim Flanigan 793-7152

Cambodia: Phnom Penh - Fogarty, Research Herb Harwell 793-4713 David Pugatch 444-8360

China - Clinton Foundation Herb Harwell 793-4713

Russia: Togliatti - Research Jodie Rich 793-4770

Africa: Ghana - Research Awewura Kwara 793-4491

358 MEDICINE & HEALTH/RHODE ISLAND 359 VOLUME 90 NO. 11 NOVEMBER 2007 Caring for HIV-Infected Refugees in Rhode Island Simon Desjardins, Curt G. Beckwith, MD, Heather Ross, LCSW, Lauri Bazerman, MS, Jennifer A. Mitty, MD, MPH In 1988, the Office of the United Nations is available and effective. Furthermore, agency, the International Institute of RI High Commissioner for Refugees many may consider HIV a “death sen- (IIRI), working with local HIV provid- (UNHCR) stressed that States and the tence” since they may have witnessed ers to assure HIV care upon resettlement. UNHCR are obliged to offer resettlement family members of friends dying from The IIRI and the Immunology Center programs to those in need of care, includ- HIV in their home countries. of The Miriam Hospital have formed a ing those who test HIV seropositive.1-2 The Data describing the HIV-infected partnership that has facilitated the re- United States did not heed this non-exclu- refugee population are sparse. Moreno settlement of HIV-infected refugees. The sion policy, and with the Immigration and and co-authors demonstrated through a Immunology Center is the largest pro- Naturalization Act, found practically all retrospective chart review of refugees re- vider of HIV care in the state and pro- HIV-positive refugees inadmissible.3 The ceiving care at Boston University that vides comprehensive primary care for Refugee Act of 1989 granted the Attor- HIV-infected refugees present with com- HIV-infected persons including social ney General discretion to waive the HIV- plex health needs, and that efforts to de- work, mental health, and substance abuse positive exclusion for certain refugees.4 liver care to this highly vulnerable popu- services. Since the majority of HIV-in- However, due to a provision set forth by lation should include screening for infec- fected refugees receive care at the Immu- The United States Citizenship and Im- tious diseases common to immigrants nology Center, we have a unique oppor- migration Services (USCIS) (then called from developing countries and assess- tunity to examine the challenges of car- the Immigration and Naturalization Ser- ment of psychological conditions such as ing for this population. vices (INS)), an HIV-positive refugee had depression and post-traumatic stress dis- The challenges include cultural and to first prove that “there would be no cost order (PTSD).3 To provide high quality language barriers, difficulty with engag- incurred by any level of a government clinical care to refugees, healthcare teams ing refugees in longitudinal care, and the agency in the US without the prior con- need to offer extensive support and em- presence of other medical co-morbidities. sent of that agency.”5 This was such a diffi- pathy and demonstrate an appreciation We presented a synopsis of our HIV-in- cult task that few of the 2.3 million refu- of the values of this diverse group of in- fected refugee patients at the 44th Annual gees who resettled in the Unites States be- dividuals. Meeting of the Infectious Diseases Soci- tween 1975 and 1999 were HIV-positive.3 Cartwright and co-authors reviewed ety of America.10 The medical charts of 47 On June 16, 1999, the USCIS revised its HIV among infected refugees in Minne- HIV-infected refugees who established policy, making it no longer necessary for sota, who were mostly from sub-Saharan care at The Miriam Hospital between HIV-positive refugees to prove that they Africa, and found an increasing propor- 2001-2005 were retrospectively reviewed. would not be a financial burden on gov- tion of HIV variants. 9 Although most The study examined demographic vari- ernment-funded programs.4 Since this re- persons who acquire HIV in the United ables, HIV history, medical co-morbidi- vision, from the fiscal years of 2000 to States acquire clade B virus, clades A, C, ties, and barriers to HIV and primary care. 2004, out of the 340,171 refugees who and D were observed among the refu- The median age of this population gained entrance into the United States6, gees in this study. These differences in was 37 (range 21-47), with 60% female. 1057 (0.31%) were HIV positive.7 HIV clade are important. Different clades Sixty-eight percent of the refugees emi- Being a refugee is a risk factor for may affect the ability to use HIV viral load grated from Liberia, and 57% originated acquiring HIV as well as tuberculosis, assays approved for clade B virus and the from refugee camps in West Africa. This parasite infections, and viral hepatitis.8 ability to identify resistance mutations was not surprising given the strong histori- Poor nutrition, the breakdown of the relevant to antiretroviral therapy. cal ties between Liberia and Rhode Island. healthcare infrastructure and immuniza- (Providence has one of the largest popula- tion programs, and the exposure to physi- REVIEW OF THE HIV-INFECTED tions of Liberian immigrants in the United cal and psychological stressors contribute REFUGEE POPULATION RECEIVING States.) The main risk factor for HIV in- to this risk.8 In addition, the conditions CARE AT THE IMMUNOLOGY CENTER fection among the refugees was hetero- that underlie conflict, such as poverty, OF THE MIRIAM HOSPITAL IN sexual sex, with 81% of the refugees re- powerlessness, social instability, and PROVIDENCE, RI porting it as their primary HIV risk fac- marginalization also contribute to psy- Of the 340,171 refugees who en- tor. In contrast, in the United States as a chological trauma.1 Due to limited or tered the US between 2000 and 2004, whole, male-male sexual contact remains nonexistent healthcare in their countries 1467 (0.43%) resettled in Rhode Is- the number one risk factor for HIV infec- of origin, refugees have substantial land; 6 42 (2.3%) were HIV-positive. tion followed by heterosexual sex and in- healthcare needs upon arrival to the This translates into a rate of HIV-posi- jection drug use.11 Among the refugees, United States. HIV-infected refugees tive refugee resettlement in Rhode Island the median CD4 count upon entering may have limited or no understanding that is 7.4 times greater than the national HIV care was 434 cells/ml (range 20- of the natural history of HIV disease, how average. In Rhode Island, the resettle- 1252) and the median HIV-1 plasma ri- it is transmitted, and whether treatment ment process involves a local resettlement val load was 8981 copies/ml (range <75- 360 MEDICINE & HEALTH/RHODE ISLAND >500,000). Of 44 patients whose initial Several elements of HIV education creased rates of pregnancy among the CD4 counts were obtainable, 16% (7/44) need to occur with a newly resettled refu- HIV-infected refugee population. This had AIDS when care was initiated. Fifty- gee. First, the provider must be sure that has led to considerable efforts aimed at three percent of the refugees completed the refugee understands the HIV diag- educating refugees of child-bearing age baseline HIV genotype testing looking for nosis and basic facts about the disease. about the importance of discussing preg- HIV resistance in persons who had never This discussion includes an explanation nancy with their HIV provider to ensure received antiretrovirals in the past. Two of of the expectations of the provider, in- measures are taken to reduce the risk of the 25 patients (8%) for whom data were cluding regularly scheduled appoint- mother-to-child transmission of HIV. available had baseline HIV resistance ments and the use of laboratory tests for which was comparable to an estimated 7% monitoring HIV disease (CD4 cell count CONCLUSION within the general patient population of and HIV plasma viral load). These dis- Language barriers, lack of under- The Immunology Center.12 Thirty-eight cussions can be complicated if the refu- standing of cultural differences, fear of percent began antiretroviral therapy gee has been raised in a culture where disclosure of HIV status to the commu- within the first 12 months of care. Forty- traditional medicine has produced a dif- nity, a general lack of understanding of five percent of the refugees were thought ferent understanding of HIV infection. preventive health care, and the integra- to have had a history of depression or post- Some refugees attribute their infection to tion of HIV care into the unsettled pro- traumatic stress disorder; 32% had ane- “witchcraft” and believe God will cure cess of refugee relocation – all impede mia at baseline; and 19% were positive for their illness. For these patients, the pro- the care of refugees who are HIV-in- hepatitis B surface antigen.10 vider should respect those traditional fected. Further research is underway, ex- In addition, 39% of the female beliefs while at the same time developing amining the differences between the refugees became pregnant since arrival a care plan that will enable monitoring HIV-infected refugee population and the to the US; 23% completed screening for of HIV disease. HIV-infected non-refugee population in parasite infections following initiation of HIV treatment, including the indi- order to better characterize the needs of HIV care; and only 13% possessed vac- cations for treatment, need to be dis- the refugees. In addition, an in-depth cination records. The low completion cussed. Treatment can be complex and analysis of the increased rate of pregnancy rates for parasite screening, which is rec- decisions are based upon the immune sta- among the refugees is being completed ommended upon resettlement from en- tus of the patient. For refugees with an to better understand the outcomes of the demic areas, is likely due to a combina- intact immune system, treatment will not pregnancies. These data will be used to tion of patients not complying with stool necessarily be recommended upon initia- inform providers who care for this vul- analysis and providers failing to order the tion of care. In our experience, it can be nerable population. Despite all of the testing. Given limited or nonexistent vac- difficult for refugees who have limited challenges, many of our patients have cination records, the majority of refugees knowledge of HIV disease to understand successfully integrated into their new needed to initiate full vaccination series why treatment would not be started right communities. However, working with once care was established. away. They may believe that medications this population requires the collective ef- were wrongly withheld from them. Ex- forts of IIRI staff, social workers, transla- CHALLENGES OF CARING FOR plaining the rationale behind delaying tors, outreach workers, case managers and REFUGEES treatment and building a sense of trust physicians. By definition, refugees flee their with the refugee may require multiple vis- country to escape persecution. Typically, its and help from social workers and IIRI REFERENCES they have little or no control over their staff members. At the same time, refu- 1. Office of the United Nations High Commissioner destination. Psychological and physical gees in need of treatment based upon a for Refugees (UNHCR). Policy and Guidelines regarding Refugee Protection and Assistance and trauma are common. Many reside in low CD4 count, but who are asymptom- Acquired Immune Deficiency Syndrome (AIDS). refugee camps for years prior to resettle- atic, may feel that treatment is not neces- Geneva: 15 February 1988. Document nos. ment in the US. Those camps can be sary. In this scenario, the patient may not UNHCR/IOM/21/88, and UNHCR/FOM/20/ dangerous without provision for take the prescribed medications. An out- 88. 2. Purdin S, McGinn T, et al. Forced migration and healthcare, education, or employment. reach nurse may be able to assist with transmission of HIV and other sexually transmitted Prior to resettlement, refugees un- medication adherence. infections.November 2001:9. \t “_blank” http:// dergo HIV testing. Communication of Finally, the provider must discuss ways www.hivinsite.org/InSite?page=kb-08-01-08 . 3. Moreno A, Crosby S, et al. Health assessment of HIV test results to the individual does not to prevent HIV transmission between HIV-infected refugees. J Acquir Immune Defic always occur. Some refugees learn of their sexual partners. This can be difficult for Synd 2003; 34:2. HIV-positive status following resettlement. persons from cultures where sexual activ- 4. Kidder R. Administrative discretion gone awry. Those who do learn of their infection prior ity is not discussed openly. With respect Yale Law J 1996; 106:389-422 5. US Government. Immigration and Nationality to resettlement, often deny the diagnosis. to pregnancy, we generally counsel our Act, 8 U.S.C. Sec. 1182(a)(1)(A)(i). One of the greatest challenges for HIV-pro- patients to practice safe sex and to avoid 6. United States Department of Health and Hu- viders in the US is to create a trustful pro- pregnancy given the risks to the child. man Services. Administration for Children and vider-patient relationship during the trau- However, refugees who have experienced Families. Office of Refugee Resettlement. Data [web site]. September 29, 2006. http:// matic time of relocation and to communi- a tremendous loss of family may want to www.acf.hhs.gov/programs/orr/data/index.htm. cate the meaning of their HIV diagnosis. create a new family. Our data suggest in- Accessed October 13, 2006. 361 VOLUME 90 NO. 11 NOVEMBER 2007 7. Department of State; Bureau of Population, Refu- Simon Desjardins, is a Research Assis- Disclosure of Financial gees, and Migration; Office of Admissions - Refu- tant, The Miriam Hospital. Interests gee Processing Center. 8. Barnett ED. Infectious disease screening for refu- Curt G. Beckwith, MD, is Assistant The authors have no financial inter- gees resettled in the United States. Clin Infect Dis Professor of Medicine, Division of Infec- ests to disclose. 2004;39:833-841. tious Diseases, The Warren Alpert Medical 9. Cartwright, CP. The changing epidemiology of School of Brown University. CORRESPONDENCE: HIV/AIDS at a Minnesota hospital. J Medical Virol 2006; 78:19-21. Heather Ross, LCSW, is a Social Curt G. Beckwith, MD 10. Kerr C, Blood E, et a;. HIV-infected refugees in Worker, The Miriam Hospital. The Miriam Hospital Rhode Island [Abstract 922]. Presented at the Lauri Bazerman, MS, is a Research 164 Summit Ave 44th annual meeting of the Infectious Diseases Society of America; 2006; Toronto, Ontario. Associate, The Miriam Hospital. Providence, RI 02906 11. HIV/AIDS Surveillance Report. Atlanta: US De- Jennifer Mitty, MD, MPH, is Assis- Phone: (401) 793-4397 partment of Health and Human Services, Public tant Professor of Medicine, The Miriam e-mail: [email protected] Health Service, Centers for Disease Control and Hospital & The Warren Alpert Medical Prevention, National Center for Infectious Dis- eases, Division of HIV/AIDS; 2005; 1-54. School of Brown University. 12. Mehta A, Beckwith C, et al. Prevalence of drug resistant mutations in ART-naïve patients at The Miriam Hospital HIV Clinic [Abstract]. Presented at the Annual Meeting of the RI Chapter of the ACP-ASIM, May 2006.

362 MEDICINE & HEALTH/RHODE ISLAND The Creative Clinican Tuberculosis Peritonitis Joseph D. DiMase, MD, FACG, FACP, and Deepak Agrawal, MD

A case of peritoneal tuberculosis in a foreign-born person is throughout the peritoneal and liver surfaces. Biopsies con- reported, where the diagnosis was established after two weeks of firmed the presence of necrotizing granulomatous disease. hospitalization. The Centers for Disease Control and Preven- Subsequent AFB cultures were positive. Fourteen days after tion (CDC)1 estimate that 50% of all cases in the US occur in admission, treatment was begun with isoniazid (INH) pyrazi- foreign-born persons. As of 2005, the rate was eight times that namide (PZA) and Rifampin. Because of the high preva- of US-born. Rhode Island has followed the national trend.2 lence of resistant tuberculosis, ethambutal was added. After Because resistant strains have developed and because the disease another 67 days, there was marked improvement although can be fatal, early diagnosis and treatment may be life-saving. the ascites was resolving slowly. Ethambutal and PZA were discontinued when positive AFB cultures from the perito- CASE REPORT neum demonstrated an organism to be fully sensitive to INH A 66 year-old man from the Dominican Republic, in RI and Rifampin. The patient was followed at the RISE TB clinic for the past 14 years, was admitted with the chief complaint of until March when he left for the Dominican Republic. He progressive abdominal distention. He was in his usual state of completed his treatment at the National TB Control Center good health until one and a half months prior to admission in Santo Domingo. when he developed increasing abdominal distention accom- panied by fatigue, generalized weakness, and anorexia with a DISCUSSION 10 pound weight loss. He reported having chills and fever Mycobacterium tuberculosis effects 1/3 of the world’s one month previously, which spontaneously resolved. He de- population and kills approximately 2 million individuals an- nied abdominal pain and other GI or pulmonary symptoms. nually.3,4 Because the disease can present in many different There was no history of alcohol use, confirmed by his family, forms, in the right clinical setting the diagnosis must be kept in and no history of tuberculosis exposure. He had been taking mind. Secondarily, delaying the diagnosis in hospitalized pa- no medications. tients increases morbidity and mortality and exposes others to His temperature was 98.1, BP 118/71, P 82, and R 20. a potentially fatal disorder.5 Pulse oximetry on room air was 97%. He appeared cachectic In RI in 2005 there were 47 reported cases of TB and but was in no obvious distress. There was no adenopathy. De- 74.5% of these were from Providence.2 Of the 47 cases, 33 creased breath sounds were noted at the right base. Cardiac were in foreign-born patients. The site of the disease was pul- exam was normal. The abdomen was markedly distended with monary in 26 cases, extra pulmonary in 17 cases and both in 4 a positive fluid wave. No abdominal masses were felt. cases. Of the 19 cases confirmed by culture, 11% were resis- tant to one drug. Foreign-born nationals in our state make up LAB DATA 11.4% of the population and since, as in our case, they are WBC 3.6, Hgb 9.6, platelets 587,000, electrolytes, BUN, more apt to be afflicted, TB must be considered in the differ- creatinine, glucose and liver tests were normal with the excep- ential diagnosis in the clinical setting. tion of an albumin of 2.0 grams/percent. Iron level was 14 Tuberculosis peritonitis is often diagnosed late in the course ug/dl with a TIBC of 146 mg/dl and a ferritin level of 318 ng/ of the disease.6 Individuals with HIV infection, cirrhosis, dia- ml. Hepatitis panel was negative. Blood cultures and cytology betes, malignancy and patients on peritoneal dialysis are at on peritoneal and pleural fluid were negative as were stains for higher risk for TB. Peritoneal infections can occur by hematog- acid fast bacilli. An abdominal CT revealed a moderate right enous spread or by direct extension from an intestinal or pelvic pleural effusion, a 6 mm pulmonary nodule at the left lung site. TB must be included in the differential diagnosis in pa- base, marked ascites and a dilated transverse colon, greater than tients presenting with fever, weight loss and abdominal dis- 6 cm. CT of the thorax showed a 6 mm nodule at the left base, comfort of more than a few weeks duration.7 a large right pleural effusion, and a partial upper lobe and In our case the PPD was negative but this test is insensitive right middle lobe atelectasis. A tuberculin skin test (PPD puri- and, due to impaired immunity, may be negative in 40-50% fied protein derivative) was negative. of cases.8 Although our patient had an abnormal chest CT it was not specific for tuberculosis. However, up to 50% of TB HOSPITAL COURSE cases have negative chest radiographs.9 A peritoneal tap was Abdominal and pleural fluid analyses revealed exudates negative for cancer cells but the fluid proved to be an exudate with a predominance of lymphocytes. AFB smears were nega- with a high lymphocytic count, a major clue to the correct tive. Because of the iron deficiency anemia, a colonoscopy diagnosis.10 As is typically the case, smears of the fluid were and upper endoscopy were normal. A laparoscopic exam of negative for acid fast bacilli. Finally, a laparoscopic exam re- the peritoneum found numerous millet-size white nodules vealed thousands of millet seed-like structures studding the 363 VOLUME 90 NO. 11 NOVEMBER 2007 entire peritoneum and biopsies revealed caseating granulomas. REFERENCES TB cultures were positive after six weeks of incubation. 1. Moloney SA et al Division of Global Migration and Quarantine. Center for Although laparoscopy under general anesthesia led to the Disease Control and Prevention, Atlanta. 2. Office of Communicable Diseases, RITB Control Program; RI Department of correct diagnosis, in the clinical setting of extensive ascites, a Health simple hook needle biopsy of the parietal peritoneum using a 3. World Health Organization 2005. Global Tuberculosis Control: Surveil- local anesthetic would have quickly provided an accurate diag- lance, Planning, Financing. Geneva Switzerland: Report WHO/HTM/TB/ nosis of caseating granulomas with substantial reduction of risk 2005 4. Raveglione MC. et al. Global epidemiology of tuberculosis. JAMA 1995; 273: and a major cost savings. 220-6. 5. Greenaway C, et al. Delay in diagnosis among hospitalized patients with active CONCLUSIONS tuberculosis-predictors and outcomes. Amer J Resp & Crit Care Med 2002;165: 927-33. TB is more common in foreign-born individuals and must 6. Lisehora GB, et al. Tuberculous peritonitis-Do not miss it. Dis Colon Rectum be considered in the differential diagnosis in the right clinical 1996; 39: 394-9. setting. The lungs are often spared and the PPD is often nega- 7. Lazarus A, Thilagar B. Abdominal tuberculosis. Disease-A-Month 2007; 53: tive. Early diagnosis and treatment is vitally important in re- 32-8. 8. Labvani A. Diagnosing tuberculosis infection in the 21st century. Chest ducing patient morbidity and mortality as well as minimizing 2007;131: 1898-906. exposure to others to this disease. 9. Lal N. Soto-Wright V. Peritoneal tuberculosis. Infect Dis in Obstet Gynecol 1999; 7: 244-7. 10. Sanai FM, Bzeizi KI. Systematic review. Aliment Pharmacol Ther 2005;22: 685-700.

Joseph D. DiMase, MD, FACG, FACP, is Clinical Assistant Professor, Department of Medicine, at The Warren Alpert Medi- cal School of Brown University. Deepak Agrawal, MD, is a third-year fellow in gastroenter- ology.

Disclosure of Financial Interests The authors have no financial interests to disclose.

CORRESPONDENCE: Joseph D. DiMase, MD, FACG, FACP 60 Creston Way Warwick, RI 02886 e-mail: [email protected]

364 MEDICINE & HEALTH/RHODE ISLAND Health Insurance Update HEALTHpact Plans for Small Employer: Physician’s Role  Matthew Stark

HEALTHpact plans are now available to small employers in PRIMARY CARE SELECTION Rhode Island from both UnitedHealthcare of New England This selection is part of the HEALTHpact enrollment pro- and Blue Cross & Blue Shield of Rhode Island. Both Blue cess, and requires Advantage-level enrollees to designate a pri- Cross’ BlueCHiP for Healthy Options and United’s Pledge mary care physician. This selection is required of all Advan- Plan will be effective October 1st for those enrolled by Sep- tage-level enrollees, of any age. No interaction with a physician tember 17, 2007. is necessary for enrollees to complete this requirement. Both United’s and Blue Cross’ HEALTHpact plans con- form to criteria set forth in the Small Employer Health Insur- PRIMARY CARE PHYSICIAN CHECKLIST ance Availability Act and by the Wellness Advisory Committee The Primary Care Physician Checklist (PCP Checklist) is to the Office of the Health Insurance Commissioner. Those required for enrollees (age twelve or older) to retain Advantage criteria include an average individual premium of no more than level-cost-sharing in their second year of HEALTHpact enroll- 10% of the average wages in Rhode Island and plan designs ment. The PCP Checklist will be provided to a primary care that create financial incentives to reduce healthcare costs by physician by the enrollee, and is also available from the insurers encouraging enrollees to establish a relationship with a primary on their websites. The Checklist must be completed and signed care physician, engage in healthy behaviors and actively man- by the primary care physician, returned to the enrollee, and for- age chronic health conditions. warded to the insurer by the enrollee no later than eight months While the premium charged to all HEALTHpact enroll- after enrollment. Completion of the PCP Checklist involves a ees will be based on an average monthly premium of no more visit with the primary care physician and requires information than 10% of the average wages, enrollees who opt for and meet on the enrollee’s Body Mass Index (BMI) and smoking status. If the eligibility requirements of “Advantage” level benefits will the enrollee’s BMI is above the recommended range, or if the enjoy lower cost-sharing through significantly lower copays and enrollee is a smoker, the completed PCP Checklist must (1) show deductibles. Advantage-level benefits are available to all that the primary care physician has discussed weight loss and/or HEALTHpact enrollees at no extra premium cost. Eligibility smoking cessation programs with the enrollee and (2) describe for Advantage-level benefits, however, requires enrollees to com- the enrollee’s program goals. There are no restrictions as to what mit to the five HEALTHpact Principles, which are: programs can be used to achieve an acceptable BMI or non- smoking status. Enrollees and primary care providers should dis- • Selecting a primary care physician, cuss options and select a best fit for the enrollee. • Completing a health risk appraisal, Physicians will not be responsible for forwarding the Checklist to the insurer or ensuring that enrollees submit the • Signing a pledge to remain at healthy weight or partici- Checklist to the insurer within establish timeframes. pate in a weight management program, • Signing a pledge to remain smoke free or to quit smok- COMMITMENT TO PARTICIPATION IN WELLNESS ing, and PROGRAMS • Signing a pledge to participate in disease and case man- Enrollees (age eighteen or older) must also pledge to par- agement programs if applicable. ticipate in the weight loss and/or smoking cessation programs in order to retain Advantage level-cost-sharing in their second HEALTHpact enrollees become eligible for Advantage- year of HEALTHpact enrollment. This pledge is intended to level benefits by submitting certain forms during both their confirm enrollee commitment to smoking cessation or weight first and second years of enrollment that demonstrate the en- loss as recommended in the PCP Checklist. Enrollees are re- rollees’ commitment to the HEALTHpact Principles. quired to note their smoking and weight status and actions HEALTHpact enrollees who do not complete the forms will taken towards participation in wellness programs for weight receive the “Basic” level of benefits, which do not provide the and smoking. No interaction with a physician is necessary for cost-sharing rewards available to enrollees eligible for Advan- enrollees to complete this requirement. tage-level benefits. Stemming the erosion of employer-based health insurance Of the forms required of Advantage-level enrollees, the coverage in Rhode Island is critical to maintaining the integrity following three are directly relevant to primary care physi- of the private health insurance market in this state. To the small cians. employer, HEALTHpact plans are a step in that direction.

365 VOLUME 90 NO. 11 NOVEMBER 2007 For more information about the HEALTHpact plans, other CORRESPONDENCE: regulatory developments and current information about the Matthew Stark efforts of the OHIC to ensure the fair treatment of the state’s Office of the Health Insurance Commissioner health care providers, please visit: www.dbr.state.ri.us/divisions/ 233 Richmond Street healthinsurance. For samples of the above-mentioned forms, Providence, Rhode Island 02903 contact Blue Cross & Blue Shield of Rhode Island or Phone: (401) 222-5488 UnitedHealthcare of New England. e-mail: [email protected]

Disclosure of Financial Interest The author has no financial interests to disclose.

Information for Contributors Medicine & Health/Rhode Island

Medicine & Health/Rhode Island is a peer-reviewed publication, listed in the Index Medicus. We welcome submissions in the following categories.

CONTRIBUTIONS Contributions report on an issue of interest to For the above articles: Please submit 4 hard cop- clinicians in Rhode Island: new research, treat- ies and an electronic version (Microsoft Word ment options, collaborative interventions, review or Text) with the author’s name, mailing address, of controversies. Maximum length: 2500 words. phone, fax, e-mail address, and clinical and/or Maximum number of references: 15. Tables, academic positions to the managing editor, Joan charts and figures should be camera-ready, or as Retsinas, PhD, 344 Taber Avenue, Providence, separate files (jpg, tif, pdf). Photographs should RI 02906. phone: (401) 272-0422; fax: (401) be saved as separate files. Powerpoint files and 272-4946; e-mail: [email protected] slides are not accepted. IMAGES IN MEDICINE CREATIVE CLINICIAN We encourage submissions from all medical dis- Clinicians are invited to describe cases that defy ciplines. Image(s) should capture the essence of textbook analysis. Maximum length: 1200 words. how a diagnosis is established, and include a brief Maximum number of references: 6. Photographs, discussion of the disease process. Maximum charts and figures may accompany the case. length: 250 words. The submission should in- clude one reference. Please submit the manuscript POINT OF VIEW and one or two clearly labelled cropped files with Readers share their perspective on any issue fac- the author’s name, degree, institution and e-mail ing clinicians (e.g., ethics, health care policy, re- address to: John Pezzullo, MD, Department of lationships with patients). Maximum length: Radiology, Rhode Island Hospital, 593 Eddy St., 1200 words. Providence, RI 02903. Please send an electronic version of the text and image to: ADVANCES IN PHARMACOLOGY [email protected]. Authors discuss new treatments. Maximum length: 1200 words. FINANCIAL DISCLOSURE FORMS All authors must submit a financial disclosure ADVANCES IN LABORATORY MEDICINE statement of possible conflicts. The form is avail- Authors discuss a new laboratory technique. able from the managing editor, or the Rhode Maximum length: 1200 words. Island Medical Society web-site (www.rimed.org).

366 MEDICINE & HEALTH/RHODE ISLAND RHODE ISLAND DEPARTMENT OF HEALTH • DAVID GIFFORD, MD, MPH, DIRECTOR OF HEALTH EDITED BY JAY S. BUECHNER, PHD Refugee Health Update: Lead Exposure in Refugee Children María-Luisa Vallejo, MA, MEd, MPH, Carrie Bridges, MPH, Magaly Angeloni, MBA, and Peter R. Simon, MD, MPH

Although there have been dramatic reductions in blood lead the city of Manchester (216). Of the 242 children, 210 were levels (BLLs) among children in the United States and Rhode tested for blood lead within 90 days of their arrival and 92 of Island in recent years, childhood lead poisoning remains a sig- them were tested again between 3 and 6 months after their nificant public health concern. In Rhode Island, among chil- initial test.5 Among the children who were tested twice, 11% dren entering kindergarten in the fall of 2006, 8% had been had elevated BLLs at the time of initial screening only, 14% found to have elevated BLLs at some time prior to age three.1 had elevated levels at both initial and follow-up screening, 29% Among children living in the state’s core cities (Central Falls, had elevated levels at the follow-up screening only, and 46% Newport, Pawtucket, Providence, West Warwick, and had no findings of elevated blood lead. Thus, many children Woonsocket), the prevalence rate was 13% of children.1 had elevated BLLs when they arrived in the US, presumably Over the last decade, an average of 70,000 refugees per from exposures in their home countries, and an even greater year have resettled in the US, with the proportion of children number were found to have acquired elevated levels from ex- ranging between 30% and 40%. During a recent 21-month posures after their arrival here. period, the majority of the 352 refugees arriving in Rhode Although data on BLLs specific to refugees arriving in Island came from Sub-Saharan Africa, most notably Liberia, Rhode Island are not available, the results from Massachusetts Ivory Coast, Ethiopia, and Somalia.2 Large proportions of and New Hampshire can be presumed to extend to them, as children arriving from those countries have been afflicted by there is substantial overlap in the countries of origin. Many of iron deficiency and chronic and acute malnutrition that put these children will arrive with elevated BLLs, and many more them at high risk for lead poisoning. Accordingly, the refu- will arrive with risk factors for acquiring elevated levels. gee health screening in Rhode Island, which is required for all refugees within 30 days of arrival, includes a BLL test CENTERS FOR DISEASE CONTROL AND PREVENTION among children up to age 6.3 Children with a BLL test result (CDC) RECOMMENDATIONS of 10 µg/dL or greater are classified as having elevated blood The CDC has developed recommendations for testing, treat- lead levels, and children who have a single venous BLL test ing, and preventing lead poisoning among refugee children: 6 result of 20 µg/dL or greater or two tests (capillary or venous) occurring at least 90 days apart but no more than 365 days • Identification of Children with Elevated Blood Lead Levels apart with levels of 15 µg/dL or greater are classified as “sig- ° Blood lead level testing of all refugee children 6 nificantly lead poisoned.”1 For children in the latter category, months to 16 years old at entry to the US. the Department of Health offers a home inspection by certi- ° Repeat blood lead level testing of all refugee children 6 fied lead inspectors to determine whether lead hazards are months to 6 years old (and older children, if warranted) present and to work with property owners to mitigate any 3 to 6 months after refugee children are placed in per- hazards identified. manent residences, regardless of initial test results. • Early Post-arrival Evaluation and Therapy EPIDEMIOLOGICAL FINDINGS IN NEW ENGLAND STATES ° Upon US arrival, all refugee children should have nu- Several studies in New England states show the prevalence tritional evaluations performed, and should be pro- of lead poisoning and associated risk factors among refugee chil- vided with appropriate nutritional and vitamin supple- dren. Among Somali-Bantu children ages 0-14 years arriving ments as indicated. in Massachusetts between April 2003 and September 2005, ° Evaluate the value of iron supplementation among 182 of 290 (63%) were found to be anemic. Among those refugee children. under age 12, 21% (33 of 157) had elevated BLLs, with 6 of • Health Education / Outreach those (4%) having levels of 20 µg/dL or greater. More recently ° CDC and its state and local partners should develop (April 2005-March 2006), among arrivals from all African na- health education and outreach activities that are cultur- tions, 26 of 193 (14%) of children were found to have elevated ally appropriate and sensitive to the target population. BLLs, with especially high prevalence rates among Somali (28%) ° CDC and its state and local partners should develop and Liberian (28%) children.4 training and education modules for health care pro- Another study, conducted by the New Hampshire Depart- viders, refugee and resettlement case workers, and ment of Health and Human Services, examined BLL test re- partner agencies (e.g., WIC) on the following: sults for 242 refugee children (ages 6 months – 15 years) arriv- – Effects of lead poisoning among children. ing in the state during the period October 2003-September – Lead sources in children’s environments and ways 2004, primarily from Africa (238) and primarily resettling in to reduce the risk of exposure. 367 VOLUME 90 NO. 11 NOVEMBER 2007 – Nutritional and developmental interventions that CONCLUSION can mitigate the effects of lead exposure. In Rhode Island, the Refugee Health and the Childhood – Ways to provide comprehensive services to chil- Lead Poisoning Prevention Programs have put in place a sys- dren with elevated blood lead levels. tem to ensure that refugees are screened for lead upon their arrival to the United States. Some refugees have already been A NEW RESEARCH STUDY exposed to lead sources in their own countries, but some oth- Under the leadership of Paul Geltman, MD, MPH, of ers are potentially exposed to lead once they are here. While the Massachusetts Department of Public Health, a retrospec- lead screening is a test that verifies the presence of lead in a tive cohort study to examine the relationship between BLL, child’s blood stream, what is really important is to eliminate behavioral practices, and world region of origin in refugee chil- the sources that cause lead poisoning in young children. The dren has been developed.7 This study addresses the relative key is to conduct primary prevention, so no child is exposed to lack of data on the subject during the past five years, a period lead and its deleterious effects. Strategies to permanently re- when the demographics of the refugee population entering move lead hazards from homes and provide healthy housing to the United States have been changing. families, along with resources to implement them, must be put This research is designed to contribute to the overarching in place and be continuously supported. goal of describing the distribution of lead exposure in refugee For additional information on lead and lead poisoning, children resettled throughout the US. There will be a focus visit the Rhode Island Department of Health’s web site, on refugees from Africa, who have accounted for a large pro- www.health.ri.gov/lead. portion of incoming refugees in recent years, as well as on iden- tifying the cultural and behavioral practices that can influence REFERENCES the risk of lead exposure. Participating states and localities will 1. Childhood Lead Poisoning Prevention Program. Providence, RI: Rhode Is- be asked to identify a sample of 30 refugees from their juris- land Department of Health. 2. Julme T, Bridges C, Simon PR. Refugee health in Rhode Island. Medicine & dictions to be included in the study so that it will represent the Health / Rhode Island 2006; 89: 347-9. situation of refugee children nationally. 3. Refugee Health Program website. Rhode Island Department of Health. http:/ /www.health.ri.gov/chew/refugee/index.php. 4. Unpublished data from the Refugee and Immigrant Health Program, Massa- chusetts Department of Public Health. 5. Kellenberg J, DePentima R, et al. Elevated blood lead levels in refugee children — New Hampshire, 2003-2004. MMWR 2005; 54:42-6. 6. Centers for Disease Control and Prevention. Recommendations for Lead Poison- ing Prevention in Newly Arrived Refugee Children. http://www.cdc.gov/nceh/ lead/refugee%20recs.htm. 7. Geltman PL. Lead Exposure in Refugee Children in the US: Research Plan. Bos- ton, MA: Massachusetts Department of Public Health. January 2006.

María-Luisa Vallejo, MA, MEd, MPH, is Coordinator of the Refugee Health Program, Rhode Island Department of Health. Carrie Bridges, MPH, is Team Lead for Health Disparities in the Division of Community Health and Equity, Rhode Island Department of Health. Magaly Angeloni, MBA, is Program Manager, Childhood Lead Poisoning Prevention Program, Rhode Island Department of Health. Peter Simon, MD, MPH, is Assistant Medical Director, Di- vision of Family Health, Rhode Island Department of Health, and Clinical Associate Professor, Departments of Community Health and Pediatrics, Warren Alpert Medical School of Brown University.

Disclosure of Financial Interests The authors have no financial interests to disclose.

368 MEDICINE & HEALTH/RHODE ISLAND Letters

TO THE EDITOR: It was with a mixture of of academic pursuits and simply anec- responsibilities to sift through available bemusement and horror that I noted dotal experience all influence the opin- opinion with a modicum of perspicac- the recent requirements under the au- ions given to us by our lectures and ity. The simple fact is that we cannot thor byline disclosing any financial in- writers. Perhaps we should have exten- indemnify information gathers and dis- terests. I have somewhat gotten used sive lists of disclaimers in which you list seminators from prejudice. It simply to the preamble of this litany at most the biotech, pharmaceutical and medi- boils down to the fact that intelligent lectures and I suppose on the surface cal facility stock holdings of your people are required to take everything this is a good thing. However, it occurs brother-in-law. While we’re at it we can with a grain of salt and look at the sci- to me that a wide variety of other dis- put down the anecdotal reports of suc- ence and demonstrated proof behind claimers should be made simulta- cess for your barber’s hair-loss treat- the contentions of any opinion. neously. Humans, and physicians are ment. To me the listing of potential con- no exception, are inherently subject to We have heard repeatedly about flicts of interest is just one more “feel all sorts of bias, financial entanglements reports of willful misleading but these good” attempt to demonstrate our hon- being only one. I think we are simply among most medical colleagues are the esty. It is ridiculously ineffective and we fooling ourselves if we think that the rare exception rather than the rule. are fooling ourselves if we believe that unvarnished truth is going to come for- Most of us try to communicate in good it is providing any significant benefit ward simply by disclosing that one is a faith what we believe to be true. Fa- in rooting out bias. consultant to X pharmaceutical com- voritism is a natural human inclination pany. Other issues such as research in- and declaring that it is so in public does Sincerely, terests, grant applications, a whole host not eradicate that fact or abrogate our Stephen E. Glinick, MD

EDITOR’S RESPONSE: I agree with Dr Glinick’s sentiments, and have written is, in fact, tied to an involved company. That does not un- a few times on the lack of correlation between mandated dercut what the doctor writes/says, but it certainly should ethics, which often translates into filling out forms while make the reader/listener more vigilant. not enhancing ethical activities, and truly ethical actions, We are all biased. My experience is different than yours. which are often not captured in “the paper trail.” I also My last three cases were different than yours. Data is data, agree that one wonders where to draw the line in establish- but how it is arrived at, how it is interpreted are all subject ing a conflict. In most conflict of interest forms the declara- to bias, conscious or unconscious. The reader should be the tions extend to spouse and children in terms of others’ in- judge, not the writer. volvement, but sometimes also list a certain sum of money Nakedness may be next to godliness. as a threshold. For example, I was excluded from writing an invited editorial because I had received more than a certain PS. I am now grappling with the fact that I am a con- amount of money from a company whose drug would be sultant to two large law firms representing pharmaceutical discussed in the article. companies in law suits related to my neurological subspe- Nevertheless I am convinced he is wrong about his sug- cialty. I have not seen any journal publish authors’ legal con- gestion that the journal not require conflict of interest state- nections, but these should bear the same weight as consult- ments. Medicine has changed so dramatically over the past ing for the drug companies directly. Of course, the lawyers two decades that it is difficult to find physicians without contacted me because of my publications. But how will that ties to industry to give talks or to write papers. It is helpful influence my future publications? Who knows? But wouldn’t for the reader, especially the more skeptical ones, who may it be better if you, the reader, knows of the connection? say, “Boy, this sounds biased,” to then learn that the author Joseph H. Friedman, MD

369 VOLUME 90 NO. 11 NOVEMBER 2007 Physician’s Lexicon The French Connection

Most medical terms are derived from Greek ness; no French phrase, though, for car-sick- A mélange of French words have infil- and Latin with a substantial aliquot from ness] and, of course, déjà vu. trated the English medical vocabulary: lav- Anglo-Saxon sources. The medical vocabulary Laennec and his many contributions to age [to wash or rinse], lozenge [originally of most Western European nations is similarly the clinical examination of the thorax heralded defining a four-sided figure such as a rhom- comprised of Greco-Latin terms plus a hand- the many French terms pertaining to the boid pill, but originally from the Latin, to ful of vernacular words. Many of our clinical chest. A rale, originally meaning a death- praise], massage [a French term derived from and laboratory terms, in addition, are taken rattle, has assumed a less lethal meaning when an Arabic word meaning ‘he was touched’], from the French medical vocabulary; and while it now defines certain abnormal breath sounds tampon [from the French, tapon, a plug to most of these words had their roots in the Clas- heard through the stethoscope. A bruit, from stop bleeding], tourniquet [from the French, sical languages, they have taken on a distinctly a French word meaning a rustling noise, now ‘to tighten’ but also the basis for the word, Gallic flavor and texture before their adoption describes a wide variety of auscultatory sounds tunic] and morgue [originally a French word by the English and Americans. mainly of the pathologic variety [eg, bruit de meaning haughty. It was first used to define Consider how many and varied medi- soufflet, the sound of a blowing murmur.] The the admitting room of police stations – where, cal phrases, from current French, color word, murmur, is also of French origin and is presumably, detainees were haughtily exam- medicine’s technical conversation: café-au- an imitative, reduplicative neologism at- ined; the word was then applied to the en- lait [coffee-colored], forme fruste [an abor- tempting to imitate soft sounds or ausculta- trance chamber of cemeteries and eventually, tive form], cul-de-sac [a dead-end alley], tory rubs. to rooms that stored cadavers.] grand mal [major seizure], petit mal [small Numerous surgical instruments carry Finally, a further scattering of French seizure], folie a deux [insanity of two], idiot- French names: curette [from the French, words readily accepted in English includes savant [a great cognitive skill, narrowly de- curer, meaning to cleanse], rongeur [from the chancre, grippe, calorie and debridement. fined, in an otherwise mentally challenged French, ronger, to gnaw], trocar [from the human], tic douloureux [a painful, usually French, trios carres, three edges] and lancet – STANLEY M. ARONSON, MD trigeminal, neuralgia]. Mal de mer [sea-sick- [from the French meaning little spear.]

RHODE ISLAND D EPARTMENT OF H EALTH VITAL STATISTICS DAVID GIFFORD, MD, MPH DIRECTOR OF H EALTH EDITED BY COLLEEN FONTANA, STATE REGISTRAR

Underlying Reporting Period Rhode Island Monthly November Cause of Death 12 Months Ending with November 2006 Vital Statistics Report 2006 Number (a) Number (a) Rates (b) YPLL (c) Provisional Occurrence Diseases of the Heart 225 2,703 252.7 2,997.0 Malignant Neoplasms 177 2,316 216.5 6,222.5 Data from the Cerebrovascular Diseases 25 384 35.9 432.5 Division of Vital Records Injuries (Accidents/Suicide/Homicde) 41 481 45.0 7,184.0 COPD 39 482 45.1 427.5

Reporting Period (a) Cause of death statistics were derived from the underlying cause of death reported by Vital Events May 12 Months Ending with physicians on death certificates. 2007 May 2007 (b) Rates per 100,000 estimated population of Number Number Rates 1,067,610 Live Births 1,041 13,652 12.8* Deaths 840 9,991 9.4* (c) Years of Potential Life Lost (YPLL) Infant Deaths (7) (96) 7.0# Neonatal Deaths (6) (65) 4.8# Note: Totals represent vital events which occurred in Rhode Marriages 526 6,828 6.4* Island for the reporting periods listed above. Monthly pro- Divorces 276 3,110 2.9* visional totals should be analyzed with caution because the numbers may be small and subject to seasonal variation. Induced Terminations 376 4,738 347.1# Spontaneous Fetal Deaths 71 966 70.8# * Rates per 1,000 estimated population Under 20 weeks gestation (65) (895) 65.6# # Rates per 1,000 live births 20+ weeks gestation (6) (71) 5.2# 370 MEDICINE & HEALTH/RHODE ISLAND advertisement

371 VOLUME 90 NO. 11 NOVEMBER 2007  

The Official Organ of the Rhode Island Medical Society

Issued Monthly under the direction of the Publications Committee

VOLUME 1 PER YEAR $2.00

  NUMBER 1PROVIDENCE, R.I., JANUARY, 1917 SINGLE COPY, 25 CENTS

NINETY YEARS AGO, NOVEMBER 1917 FIFTY YEARS AGO, NOVEMBER 1957 Roland Hammond, MD, in “The Stiff and Painful Shoul- A.A. Savastano, MD, in “Recurrence of Convulsive Sei- der,” traced the cause either to injuries, such as dislocations, or zures Complicating Steroid Therapy.” discussed two patients diseases, such as subachromial bursa, arthritis, and tuberculo- who developed seizures after receiving meticorden. One pa- sis. tient, who had epilepsy, had been seizure-free for the previous Charles A. McDonald, MD, in “Some Remarks on Ex- 10 years; the second patient developed seizures after an opera- ophthalmic Goitre,” discussed the symptoms for 6 of 15 of his tion for a brain tumor. cases. The symptoms included hyperthyroidism and blood pres- Alfred F. Tetreault, MD, in “Merits of 2-hour Post-Pran- sure. dial Blood Sugar Screening Test,” reported that he found it Delos J. Bristol, Jr, MD, in “The Percy Operation,” praised “more sensitive and reliable than a fasting blood sugar.” this…” method of applying heat both to inhibit and destroy Seebert J. Goldowsky, MD, discussed “The First Appen- inoperable carcinoma of the uterus and vagina,” developed in dectomy in Rhode Island.” Nationally, the first successful ap- 1912 by Dr. F. Percy of Galesburg, Illinois. Dr. Bristol sug- pendectomy was probably performed by Thomas G. Morton, gested: “In obese women it offers the only chance for a perma- MD, Philadelphia, in 1887. In 1882 Robert Noyes, of Provi- nent cure.” dence, read a paper before the RI Medical Society. He had During World War I, Rhode Island’s hospitals and clinics collected from the literature and from his own experience 100 were under-staffed. An Editorial, “The Civil Clinic in War cases of perityphlitic abscess treated by surgical drainage (mor- Time,” called on physicians in Rhode Island to fill the gap left tality was 15%). In February 6, 1893, Dr. George L. Collins, by physicians serving overseas. “Inasmuch as it is the American of Providence, performed the first appendectomy. The patient people and not merely the American armed forces that are at recovered. war with Germany, the obligation for service is universal…” “..every physician who is in practice should be ashamed not to TWENTY-FIVE YEARS AGO, NOVEMBER 1982 be on duty in at least one public clinic every day throughout Glenn W. Mitchell, MD, in “Emergency Medical Tech- the period of the war.” nicians in RI: An Overview,” noted “Support and involvement of physicians is necessary for the design and implementation of a paramedic program.” Alex M. Burgess, Jr, MD, and William H. Meroney, MD, discussing “Health Maintenance,” noted “Certain fallacies in the conventional wisdom regarding nutrition and lifestyle.” Gerald A.Faich, MD, MPH, and Robert Mullan, MD, contributed “Hospitalization for Tuberculosis.” “The hospital stay is prolonged by the delay in …the diagnosis and non-tu- berculosis problems.” Of 107 cases discharged throughout one year, 57 had a primary diagnosis of TB; 50 had a secondary diagnosis. Most (87%) of newly diagnosed patients were hos- pitalized in 1979.

372 MEDICINE & HEALTH/RHODE ISLAND

integrity

whatdrivesyou?

Whatever it is that sustains you through the daily challenges of your profession, know that you have an ally in NORCAL.

(800) 652-1051 ● www.norcalmutual.com

Call RIMS Insurance Brokerage Corporation at (401) 272-1050 to purchase NORCAL coverage.