Where Are They Now: Fulbright Scholar Studies Palliative Care in Malaysia

5 03 2013

By Lisa Deng
Duke Alumna, Global Health Certificate ‘12
Fulbright Researcher


Lisa Deng (middle) with an oncologist and radiographer at the Sarawak General Hospital Department of Oncology, Radiotherapy, and Palliative Care.

I was first exposed to palliative care during fieldwork in rural Uganda through the Duke Global Health Institute where I worked with a physician to assess the needs of terminally ill people in a community lacking treatment for life limiting diseases such as HIV/AIDS and cancer. Seeing firsthand the extreme and largely preventable human suffering, I became interested in efforts to support people facing the end of their life in resource-limited settings.

After graduating from Duke in 2012, my interests in palliative care and global health brought me to Malaysia through the Fulbright Program where I am conducting qualitative research in four government hospitals across two states. Under the mentorship of Duke Global Health Professor David Boyd, I am collaborating with two physicians pioneering palliative care services in Malaysia to explore the communication needs and preferences of patients with advanced cancer and their families.

In my interviews, I am gaining an Asian perspective on expectations at the end of life. The important role of family is a value shared across the diverse cultures of Malaysia. Family members, such as the eldest son, are often responsible for liaising with the doctor and making decisions for the patient. It is not uncommon for families to hide certain information from the patient, such as poor prognosis. On one occasion, I witnessed an older patient who thought she was renewing her prescription for gastritis when she actually had stage IV lung cancer. Family members tell me they wish to protect the patient from the truth, fearing their loved one would become depressed and lose hope.

Because death is taboo in many Asian cultures, I anticipated this phenomenon. To my surprise, many patients also prefer and contribute to this “conspiracy of silence.” During interviews, some patients tell me they see no value in burdening themselves with knowledge of poor prognoses if they cannot change the outcome. Rather, they prefer to live each day with optimism. It is unclear whether patients and families would favor open and honest communication if comprehensive palliative care services were more widely available to provide emotional and spiritual support. However, it does underscore the need for doctors in Malaysia to be sensitive to information needs and work with the patient and family as a unit.

These past seven months in Malaysia have been extremely meaningful and rewarding. I am thankful for my global health education at Duke, which has prepared me to transform compassion and empathy for other human beings into concrete ways of serving. The lessons that I carry with me from courses, fieldwork, and mentors guide me through the difficulties of this work. The grief and loss I encounter on a daily basis can be intense and emotionally exhausting. But amidst all of the suffering, I have seen love and hope. In our conversations, patients share with me their histories, their dreams and fears, and their thoughts about living and dying. From them, I have learned about what gives life value, about acceptance and fortitude, and I am reminded that even in the face of death, there is always hope– hope for meaning, for friendship, for wisdom, and peace.


Where Are They Now: DGHI Alumna Shares Global Health Corps Experience

15 01 2013

DGHI alumna Alexa Monroy shares how her time at Duke prepared her for the Global Health Corps experience

By Alexa Monroy

Duke alumna with global health certificate
Global Health Corps Fellow

alexa monroy gh corpsWhen I read the description for the Global Health Corps’ Social Protection and Health Fellowship, it seemed like all my past experiences had suddenly fallen into place. The position was in Washington, DC at the Inter-American Development Bank (IDB), but I would get to travel often to Central American countries. We would be working on projects to improve maternal and child health markers for vulnerable populations in the region. As someone who was pre-med, interested in global health, and had strong ties to Central America, it seemed like the job had been designed for me.

To my surprise and complete delight, I was chosen as one of the two co-fellows for the position. The first step was to attend a two-week orientation at Yale, where I realized that this year was not only going to help me grow professionally – towards a career that fuses clinical medicine and health policy – but also bring me into an amazing community of people who want to build a “global health movement”. To achieve this, Global Health Corps (GHC) organizes retreats throughout the year that teach fellows to communicate their vision, become better leaders and learn from their peers. So far, both the IDB and GHC have allowed me to understand the day-to-day work of someone who is engaged in both international development and health.

At the IDB, most of my projects are part of an initiative called Salud Mesoamerica 2015 (SM2015). The initiative is funded by the Bill and Melinda Gates Foundation, the government of Spain and the Carlos Slim Institute (you can read more about it here: www.sm2015.org). The main goal of the initiative is to assist Central American governments in addressing the maternal and child health issues that they prioritize. I’ve worked on many different projects, like a supply chain analysis in Chiapas, Mexico, and the revision of national guidelines for birth control counseling in Panama. I also co-authored a technical note that encourages regional cooperation to eliminate micronutrient deficiencies in vulnerable populations. All these projects have helped me understand the role of development banks in health planning and financing, and how their work can influence health policy.

My plan right now is to go to medical school next year, so it was important to me to gain experience working for a multi-lateral organization to have a clearer picture of the career I’d like to have. I ultimately see myself working in a policy position and traveling with medical teams to care for patients in low-resource settings and build capacity on the ground. This way I could interact with people and have the tools to cure disease, while also sharing information with key players in global health to put in place health interventions that are effective in the developing world.

Although I went to Duke knowing I wanted to be a doctor, the unique experience of being part of pre-med classes and the Duke Global Health Institute broadened my horizons and helped me carve out a particular niche in the global health field. I always appreciated Duke’s enthusiasm for multi-disciplinary career paths that tackled a real-world problem through innovation and service. If it weren’t for Duke and DGHI, I would never have understood the range and depth of what can be done to improve health around the world, and I would not be having the time of my life as a GHC fellow at the IDB today.

Check out another blog I wrote about my GHC experience. If you’re interested in applying to GHC, do it soon! Applications close February 3 (www.ghcorps.org).

My Visit to India as a DGHI Doctoral Scholar

19 12 2012

By Jie-Sheng Tan Soo
DGHI Doctoral Scholar

jie-sheng1I went to India for the first time last summer to learn and observe how fieldwork is conducted and to understand what life is like in a low- and middle-income country. It was my first time in India, and my first research trip as a DGHI Doctoral Scholar.

I’m a PhD student in the Nicholas School of the Environment working with my supervisor and mentor, DGHI faculty member Subhrendu Pattanayak, on research projects related to water and sanitation and improved cookstoves. I’m excited to be working with Dr. Pattanayak.

My first stop in India was the mountains of Uttarakhand, where I worked on the improved cookstoves project. To reach Uttarakhand from Delhi, we took a four-hour train ride and a three-hour car ride up winding, narrow and unpaved mountain roads. This long and at times dangerous journey was worth it as I could escape from the sweltering summer heat of the plains.

We were trying to determine the desired features of improved cookstoves and how to encourage usage of these cookstoves among rural households. For the ten days I was there, I helped with staff training and participated in household surveys. While I have worked with datasets collected by others, this was the first time I was part of the data collection process. This experience allowed me to put a ‘face’ to the datasets. It also gave me a new appreciation for the hard work that goes into data collection and for the time people give up in order to provide us with information.

jie-sheng2After a week and a half, I begrudgingly bade farewell to the mountains and their lovely people as I proceeded to the state of Orissa in the eastern part of India. This is one of the poorest states in India and signs of their relative poverty were obvious everywhere.

While in Bhadrak district, which is located at Orissa’s coastal area, I surveyed villagers involved in the 2005 sanitation evaluation study led by Dr. Pattanayak and others. This study was initially designed to examine whether subsidies and/or social pressure on open-defecation would lead to higher adoption of latrines. The team is following up to see if the adoption was sustained and, more importantly, if there were improved health impacts because of the use of latrines. During this particular visit, I met with rural villagers and gathered preliminary information on the sustainability of that project. Some villagers complained about the poor quality of the latrines while others seemed proud to have one. Regardless of their attitudes toward latrines, I was almost always invited for a cup of hot Chai. On a more somber note, I noticed animal feces in the village, possibly making it more challenging to quantify improvements in health from latrine use.

The highlight of my two weeks in Orissa was visiting and interviewing villagers. They welcomed me and treated me to many new and interesting sights. In Uttarakhand, I coordinated my visits with the help of a native, who happened to be a fellow Duke student. All these hands-on efforts made these visits more satisfying.

The last leg of my trip was in Maharashtra, where the financial capital Mumbai is located. Upon arriving in Mumbai, I was overwhelmed by a sense of familiarity as the high-rise buildings, luxury cars and well-paved roads reminded me of my native country of Singapore. At the same time, I was made painfully aware of the wide wealth disparity as Mumbai is home to some of the largest slums in Asia.

Similar to my time in Orissa, I visited areas like the rural district of Nashik to interview villagers about their water practices and health needs. The top health concern for this community is water availability. Due to the scarcity of this natural resource, the community wanted a more reliable source of water. The more fortunate ones had water tanks to store excess water. However, during the long dry season, the water in the tank is used up quickly. I asked whether having water tanks in their village helped to reduce cases of diarrhea. Their answers seemed to be inconsistent — everyone had a different idea of what diarrhea meant to them. This is a good reminder that anthropometric health measurements are needed in addition to self-reported health status.

Since making the decision to work on health issues in the developing world, I have the nagging thought of whether this city-dweller can fully understand the daily challenges the locals face and if I have ability to make a difference. My trip to India has made me realize that I still have a long way to go, but I have taken that important first step. I look forward to returning to India soon to continue this important research.

Engagement Through a Common Language Goes a Long Way

10 11 2012

By Jen Rackliff, MSc-GH student
from her fieldwork location in Rwanda

jen-rwanda2012Every morning, I come to the porch, also known as my “office”, and sit perched atop the hill overlooking the beautiful hills of Rwanda (pictured here). It’s a painting-worthy view and one I never tire of, but it is not quite how I envisioned my fieldwork to be.

For my self-designed internship, I am helping an international global health organization move its community health research agenda forward – both in supporting their current research and through my own research project. I envisioned regular field visits and closer interactions with community members and health care providers – seeing community health delivery firsthand. I quickly realized that was not quite how it would play out.

Though I learned in my first couple of days that I wouldn’t be so intricately involved with the surrounding communities, it still seemed as if I would be doing some incredible things, like helping identify study designs and methods for developing impact evaluations of community health programs. But, even this wasn’t quite as glamorous as I had envisioned. What it actually meant were days filled with conducting background research and literature reviews, which made my days a bit humdrum and unexciting. I knew I could not sustain a four-month internship this way – I needed to get more involved and be more active!

So, the first step was asking my Rwandan co-workers for ikinyarwanda lessons. Even just learning greetings and conversational phrases has helped me interact with local Rwandans, both at work and in the villages. I have developed closer relationships with my team and others throughout the organization that have opened doors for me to become more involved at both the organization level and the community level.

I now support my team on their current projects from back-translating study tools to conducting general research on current studies. I have been to the field to observe data collection and I regularly get invited to community health meetings held throughout the District. All of the field visits, data collection, and community meetings are in ikinyarwanda, which I don’t understand, but just attending is a learning experience! I’m thankful that I am able to properly address people and introduce myself.

Many places that MSc-GH fieldwork will take you will have difficult languages to learn, but the best lesson I have learned is how many doors can be opened by attempting to learn language – both professionally and socially! I often get laughed at when pronouncing (or, rather, mispronouncing) words and phrases and when I don’t understand the responses that people give me. But, my small arsenal of ikinyarwanda phrases and words is ever-growing, and the learning and laughter that comes from them, are what brings me closer to my friends and coworkers. It may be embarrassing at times, but I wouldn’t change it for anything!Many of my non-Rwandan coworkers and friends have commented about the things I have done and the opportunities I have had after having only been here for a month. I owe most of my experiences thus far to being able to engage, even if only superficially, through language.

Why Health Commodities Aren’t Reaching People Who Need Them in Laos

7 10 2012

By Madeline Boccuzzi, MSc-GH student

Spending a summer in Laos was a great way to complete my global health thesis research. Southeast Asia has much to offer including amazing food, kind people, glimmering Buddhist temples, and gorgeous landscapes. The work was fascinating and productive, and all in all, it was an incredible experience. I look forward to going back.

maddylaos1I knew very little about Laos before I started my fieldwork preparations, so a bit of a primer before I get into the meat of my work. Laos is a small, landlocked country sandwiched between Thailand (to the west) and Vietnam (to the east). It also shares borders with Myanmar (Burma) and China to the north and Cambodia to the south. The country is roughly shaped like a palm tree, and the capital city Vientiane sits on the western border where the trunk turns into fronds. The total population is just over 6 million people with about 700,000 people living in the capital. Laos is a communist country, but the government has allowed large-scale development projects in huge swaths of the country and is en route to losing its Least Developed Country status by 2020.

My fieldwork project evaluated Laos’ HIV and malaria procurement and supply chain processes. Supply chain and procurement challenges have a direct impact on health outcomes in Laos. Working through the World Health Organization (WHO) country office in Vientiane Capital, I was integrated into the Lao Ministry of Health’s (MoH) national HIV and malaria units in an effort to identify why health commodities do not reach the people who need them most. The WHO works intimately with the MoH, and both entities have identified procurement and supply chain management of health commodities a major public health concern in Laos.

Procurement and supply chain management can mean different things in different contexts, but my research is limited to what happens once commodities arrive in country and the process they go through to get to patients throughout Laos. I focused on HIV test kits, malaria test kits, and Artemisinin-based combination therapy (ACT) tablets to treat malaria in an effort to map the supply chain and procurement processes in Laos. These three commodities are particularly relevant in the Laotian context because of rampant HIV test kit stock outs and a three-fold increase in malaria incidence rates in 2012.

Laos does not have one single factor that would yield a challenging supply chain situation – HIV prevalence rates are low (0.2% in 2011), malaria has been controlled (3,837 cases; 17 deaths in 2011), there is decent infrastructure in place to reach the provinces, the government acknowledges weaknesses in procurement and supply chain management, and the Global Fund for AIDS, Tuberculosis, and Malaria has ensured that there is not a dearth of funding for HIV and malaria programming. This makes the HIV and malaria supply chain failures in Laos perplexing – a small country, with a small population and relatively low rates of infection and disease should be able to test and treat its population accordingly. Unfortunately, this has not been the case in recent years. HIV test kits have been in low supply or stocked out countrywide, resulting in areas with selective testing or none at all. As one of my interviewees said, “Not having [HIV] test kits is the worst possible problem a [HIV] program can have.” The best-laid HIV program plans are useless if you cannot test people for HIV.

maddylaos2Unlike HIV, malaria in Laos is seasonal. Malaria transmission follows the rainy season, which is roughly early May through the end of September. Malaria commodities (insecticide treated bed nets, malaria test kits, and ACTs) must be delivered to at-risk areas prior to the rainy season for effective malaria prevention and treatment. Delays in receiving bed nets and delays in distributing them to the provinces have caused a significant malaria outbreak in the South. There have already been 11,221 malaria cases and 12 deaths from January –May 2012, a shocking three-fold increase from 2011 year end statistics.

My research interests in supply chain management aligned with a great need for clarity on the current health situation in Laos. The MoH and the WHO know all too well that supply chain failures negatively impact Laotian health, but where and why the supply chain fails had not previously been studied. I conducted 35 key informant interviews with health care workers at all levels of the supply chain in an effort to understand the barriers and bottlenecks they face. I spent a week in the southern province Savannakhet and met with people who are actually using health commodities at the point of care and must face patients who are unable to get the products they need. In addition, I sat in on almost all procurement-related meetings during my time in Laos, which allowed me to see firsthand how these issues are being handled. These data collection methods afforded me unprecedented access to what makes the supply chain tick and gave me the opportunity to work with key players to help solve problems.

While the data is still being analyzed, I can report that there is no one reason why commodities are not reaching patients, but rather a complex web of coordination and management issues that you might expect to find in any organization throughout the world. The issues fall on a continuum ranging from systematic challenges (i.e. the human resources available) to implementation/technical challenges (i.e. storage of goods). Although this seems daunting and there is not one magic bullet that can solve all of the supply chain challenges in Laos, there are intermediate steps that can help address specific problems, ultimately improving the system step by step. Seemingly small changes such as making reporting forms for village health workers easier to fill out would make a big difference all the way up the chain.

A Changing Perspective on Global Health Outreach

26 04 2011

By Wendy Zhang
MS III, Duke University School of Medicine

It’s amazing how quickly time passes. Early in March 2010, Honduras was still a dream away, and now in April 2011, I can say that it’s the 4th most visited country of my life, that I saw and treated a fraction of the ~1000 people our group has seen and treated in the past 2 years (some of them double, triple, quadruple, or more-counted…), that I shed tears after glimpsing some of the hardships the people we treat face every day, that I met amazing people who have helped me grow as a person and as someone entering the medical professions (both within our medical group and those within the communities we visited), and that I’ve read two books that have opened my eyes to some of the world’s less-spoken-about stories of suffering and bravery (“Enrique’s Journey” and “Half the Sky”).

Having had the opportunity to see Honduras twice, I’m also amazed at how many things had changed in a year and also at how many things stayed the same. A year ago in Las Mercedes, there was no electricity for miles around, no “western” flushing toilets, no showerhead that was more than waist-high, (and no ginormous spiders…). The clinic didn’t have painted walls or tiled floors or a working kitchen. These were luxuries, though still elusive to the people in those communities, that greeted us this year when we arrived. It’s amazing how these comforts that we so take for granted here can change your experiences in Las Mercedes; for instance, you really come to appreciate those flushing bathrooms situated in tiled lit rooms at 2am in the morning when 5-6 of you are sick with a GI bug.

But the things that haven’t changed are also striking. The women still get up at 3am to start breakfast, the men (and children) at 4am before heading to “el campo” or the fields to work. The majority of children still only get 6 years of education before joining the work force at age 12-14; a handful get an additional 2 years by walking 2-4 hours on the mountain road to the regional school that offers those extra years of education; and very rarely does a young student get the opportunity or monetary fund to attend a technical university (to become a teacher, nurse, etc.) in La Esperanza, the closest town that also houses the nearest hospital. Almost everyone we see during our 5 days in Las Mercedes still has chronic back/shoulder/neck/knee/leg pain, headaches and dizziness from dehydration, chronic cough from working with pesticides or dust in the air or smoke in their houses from lack of a chimney. These hardships that few of us can imagine enduring for as long as they have and that initially gave us pause when we first heard them from the people we were treating start becoming matter-of-fact with each family you meet. For them, it’s simply how life is, and for you, it becomes “normal” to treat people whose symptoms result mainly from environmental factors.

The really difficult moments come when you meet families who, on top of the normal trials and hardships of daily living, are also met with the tragedy of illness. Last year, there was a woman who had never owned shoes in her 60-some years and a questionable case of child abuse in a little girl who came in with a subconjunctival hemorrhage. This year, there was a 58 year old man with asthma and bilateral wheezing that even a medical student couldn’t miss who worked in the fields and who couldn’t afford rescue inhalers; on top of this, his wife was battling symptoms of senility. There was also the mother with a baby who likely had trisomy 13 or some other syndromic disorder who came seeking help. Then there was the man who admitted to alcoholism who was sobering up from having drunk 2L of the local moonshine 2 nights ago, who had 4 children at home – the youngest only a few years old.

These stories make it hard going back to Honduras. Not because I’m confronted by sad experiences, but because of the helplessness I feel sometimes. But it’s because of these lessons and experiences and interactions that make me a better person and that will make me a better healthcare provider. I’ve learned there’s a big change in perspective that comes with global outreach (for if there’s anything that will cure a student’s obsession and compulsion over past letter grades and exam scores, it’s meeting people with real problems and hardships AND seeing them deal with it).

I said last year in my post-trip reflections that I hope I impacted the people of Intibuca with at least 20% of what I personally gained from this experience. I feel the same this year. I’m incredibly appreciative of the opportunity to return to Honduras and interact with the people in the community in clinic and out of clinic. I love having seen the children there last year and seeing them again this year taller and more mature (but still youthful and energetic as they hiked with us on our community tour, and as they recounted their soccer victories over children in neighboring communities, and as they repeated English words and phrases, and corrected our Spanish). I love learning more about some of the people in the community this year that I didn’t get to do last year: like Ernesto from Las Mercedes who has a great appreciation for all types of music around the world – his radio being his one connection to the outside world – and like Delsi, the precocious and incredibly smart girl from El Rosario who wishes to become a doctor and who taught me her secret handshake. I love going back to their church and seeing their services and hearing their voices in song. I love watching Gloria, our Heifer International contact, interact and counsel people in the community. I love that I got to be a part of an interdisciplinary group working together to effect a little change in these people’s lives. And I love being part of an outreach group that through building the health clinic has changed and is changing the communities’ way of life for the better.

Read more about the Honduras trip this spring in “Duke Students Experience Global Health in Honduras

Health Systems & Illness Systems

1 07 2010

On behalf of Aaron Stoertz, an MSc-GH student who is interning this summer at the World Health Organization:

“In a few days I will mark my one month anniversary as an intern at the World Health Organization in Geneva. I’m still very much on the steep part of the learning curve here in many ways– from unfamiliarity with the local language (French) to the WHO process to even the content of my work. That’s not a bad thing, I like being in places where there’s a lot to learn.

The WHO (and Geneva in some respects) looks at problems from 30,000 feet and tries to produce recommendations and guidelines to solve them from that high. At 30,000 feet (where the air is a bit thin and the horizon a bit fuzzy) problems become harder to get your arms around and the interconnectedness of our world really becomes more evident. From up that high, boundaries are difficult to differentiate. And I haven’t yet even started my policy course with Dr. Anthony So yet, a man famous for framing and attempting to solve some unbelievably complex global health problems. The course starts next week, and I’ll be sure to post about it…”

***Read more about Stoertz’s first month interning at The WHO.***

Aaron Stoertz is in the Master of Global Health program at Duke University. He is participating in the Global Health Track of the Duke Program in Global Policy and Governance and is working as a human resources for health intern at the World Health Organization.

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