At a pediatric HIV/AIDS clinic in Romania, a small child is given the antiretroviral drugs that will save his life. A premature infant in Malawi breathes easier thanks to a cost-effective and location-appropriate device, while down the road, budding Malawian doctors train to provide care for their countrymen. Each of these events is connected by a common thread: a Texas Medical Center institution that has embraced the idea that medicine knows no borders, no socioeconomic background, no race or ethnicity. That part of being a world-class provider of health care and education means giving back on a global scale.
From clinical care to research and education, TMC institutions have committed resources to dozens of countries. One of the longest-running global outreach programs in the medical center is the Baylor International Pediatric AIDS Initiative (BIPAI). In 1996, a chance encounter with a member of Romania’s parliament brought BIPAI President and Founder Mark Kline, M.D., to Constanta, Romania, then the pediatric AIDS capital of the world. During a recent presentation to Baylor medical students, Kline recounted that first visit.
“Everywhere I went, I saw HIV and AIDS-infected children warehoused, waiting to die, without any prospect of antiretroviral drugs that were being used to treat children in the U.S.,” he said. “Whole wards of abandoned children in hospitals with no medical treatment, no socialization.”
Kline, now the J.S. Abercrombie Professor and chairman of the department of pediatrics at Baylor College of Medicine and the Ralph D. Feigin Chair and physician-in-chief of Texas Children’s Hospital, returned with a new sense of purpose. He gathered enough funding from a variety of sources, from Elton John to Catholic nuns, to found the first BIPAI clinical center of excellence in an abandoned orphanage in Constanta.
“We saw 165 people the day we opened and we never looked back,” Kline said. In just a few years, the death rate in Constanta dropped from 13 percent to less than one percent. Today, BIPAI continues to treat patients in centers of excellence around the world.
“We still have a strong commitment to HIV/ AIDS work, but we do work in a number of other areas as well,” Kline said. “We never want to turn a child away, whether he has HIV or meningitis.”
Additionally, BIPAI founded the Pediatric AIDS Corps, now known as the Texas Children’s Global Health Corps—essentially a Peace Corps for physicians. Global Health Corps physicians commit a year or more to working in one of BIPAI’s locations around the world.
“To the extent possible we hire local physicians, but in many of the places there are almost no doctors,” Kline said.
Take Botswana, for example. Over the course of several decades, the government sent nearly 3,000 students abroad to study medicine. Very few ever returned.
To combat the so-called “brain drain,” Baylor and BIPAI teamed up with the University of Botswana to found a medical school. Major Bradshaw, M.D., formerly dean of student affairs and education and senior vice president at Baylor, served as the founding dean and lived in Botswana for three and a half years.
Bradshaw described a strict curriculum to prepare students for working independently early on in their careers.
“They graduate from medical school, they do an internship and then they’re assigned by themselves to a remote village,” he said. “They have to be able to deal with whatever comes through their door.”
For the first year, Bradshaw was the sole medical school faculty member. By the time he left, the school had 26 faculty members. The first class of the Botswana School of Medicine graduated in October 2014.
This need for doctors inspires the work of another TMC initiative: the Global Women’s Health program operated by Texas Children’s Hospital and the Baylor Department of Obstetrics and Gynecology. The program is based in Malawi, where there were 12 OB-GYNs for a country of over 13 million people when it was founded in 2012. The Global Women’s Health program aims to change that by training Malawian doctors in their own country.
“They will then train the coming generations and at some point, they won’t need us,” said Michael Belfort, M.D., Ph.D., obstetrician and gynecologist-in-chief at Texas Children’s and chair of the department of obstetrics and gynecology at Baylor. “That’s the goal.”
There are currently 12 residents in training, which means when all are fully trained, the number of OB-GYNs in the country will double.
“[The residents] are already thinking about how they can give back to the program and keep it going,” said Susan Raine, M.D., vice chair of Global Health Initiatives at Texas Children’s and an associate professor in the department of obstetrics and gynecology at Baylor. “In five or 10 years, we hope they want us to be there, but we don’t want to be needed.”
In July, the program initiated the Global Women’s Health Fellowship. In Malawi, the fellows learn and provide care in ways they never will here in the United States. Obstetric fistula, for example, is a condition caused by prolonged or unattended labor that results in incontinence. While it is almost unheard of in the U.S., it is commonplace in many parts of the world.
“In all of my training in this country, I saw it twice,” said Raine. “In Malawi, our doctors will do maybe eight of these surgeries a week. Even though we don’t see it here much, it still enhances the skill sets of our trainees coming back to practice here.”
The Global Women’s Health program also works to increase the resources available to doctors in Malawi. A current objective is to establish a laparoscopic surgery program.
“One of our goals is to create an environment where doctors want to stay in Malawi because they have those tools,” Raine said. “Right now, they haven’t had the ability to gain and maintain the equipment. People can donate, but if it breaks and there’s no one to fix it, the program stops.”
Rebecca Richards-Kortum, Ph.D., Rice University’s Malcolm Gillis University Professor and professor of bioengineering, made a
“If you had a big checkbook and could just buy all the same devices we use in Houston, you would find those devices stop functioning because they break or you don’t have the resources to use them safely and effectively,” she said. “You need to design for the environment where you actually need to use the technology.”
Designing for low-resource environments is a cornerstone of Richards-Kortum’s work as director of the Rice 360 ̊: Institute for Global Health Technologies. Since 2007, Rice 360 ̊has been working in Malawi to engineer innovative solutions to health problems, with an emphasis on pediatric technology. Working with the Queen Elizabeth Central Hospital in Blantyre, Rice 360 ̊ developed a continuous positive airway pressure (CPAP) device to help premature infants in respiratory distress.
Traditional CPAP machines cost close to $6,000 and require infrastructure not available in Malawi. The prototype Rice 360 ̊ built
“We worked with physicians at Texas Children’s Hospital to show that it did deliver the right amount of flow and pressure, and we carried out a clinical evaluation of it at Queen Elizabeth Central Hospital,” Richards-Kortum said. “We were able to show that for the premature babies with respiratory distress, survival improved from 24 to 65 percent.”
The device is now being used at 28 hospitals in Malawi, as well as hospitals in Tanzania, Zambia, South Africa and a number of other African and Southeast Asian countries.
Rice also offers a minor in global health technology. Students work in teams to tackle a design challenge with the goal of developing a prototype by the end of the semester to take back to Malawi.
“Often when you hear about global health disparities in the news, it’s hard to understand what the impact of that is on an individual level,” Richards-Kortum said. “When our students travel and have the opportunity to be part of the team that’s trying to provide care in a setting like that, they come back with a new sense of purpose and inspiration to address health disparities.”
In our increasingly connected world, a global perspective has become a priority for students. With that in mind, TMC institutions are offering more opportunities to study and practice outside the United States. One such program, the Center for Global Nursing Scholarship (CGNS) at Texas Woman’s University, dispatches students around the world, with trips to China, Indonesia, Korea, The Netherlands and Peru, just to name a few.
“We want our students to have an appreciation for what nursing is globally and what they can do to contribute during their professional lives,” said Joan Edwards, Ph.D., an associate professor and director of CGNS at TWU. “We are so blessed in the United States with our knowledge and resources, and we need to share that.”
Edwards emphasized that the goal of all trips is to be mutually beneficial to TWU students and the citizens of the countries they visit.
“It’s not like, ‘Hey, we’re here and we can teach you everything.’ It’s that we can learn from each other,” she said. “They have circumstances that they have been creative in solving to advance nursing, and we can learn from that and both benefit.”
The program began in 2001 and was approved by the Board of Regents as an official Center of Texas Woman’s University in 2012. CGNS goes on several trips each year. Students work on research and in clinics, and participate in international nursing conferences. A group of students recently had the unique opportunity to interview Japanese nurses who treated victims of the Hiroshima atomic bombing.
CGNS has been involved in some locations for years. The intent is not to travel to a place once, do what they can and then move on to the next location. CGNS is looking to establish true partnerships and collaborations in each country.
“This is long-term work,” Edwards said. “We’re committed to working with people in these countries for years. You’re not going to get much done in one visit—it takes relationship building.”
For Sheryl McCurdy, Ph.D., principal investigator of the Tanzanian AIDS Prevention Project (TAPP) and an associate professor at The University of Texas Health Science Center at Houston (UTHealth) School of Public Health in the department of health promotion and behavioral sciences, local relationship building is a key to success.
Through in-depth interviews, McCurdy discovered Tanzanian women injecting heroin were sharing blood, a practice called “flashblood,” to help friends avoid withdrawal. McCurdy also presented findings showing 42 percent of intravenous drug users in Dar es Salaam were HIV positive. As a result, the Tanzanian government, along with the CDC and PEPFAR, issued a call for outreach programs, leading to the development of TAPP—a partnership between UTHealth and Muhimbili University of Health and Allied Sciences in Dar es Salaam.
With the help of Tanzanian community-based organizations (CBOs), TAPP maps out areas where intravenous drug users congregate. TAPP trains CBOs and sends mobile vans to those areas to conduct outreach and educational activities. The program began by offering bleach kits and teaching people to sanitize needles. In 2011, TAPP expanded to connecting users with their families and bringing the users into its new methadone clinic, the first public access clinic in Africa. There are now three addiction treatment clinics in Dar es Salaam that have enrolled nearly 3,000 people, and Kenya has opened two methadone clinics based on TAPP’s model.
McCurdy’s next goal is to expand to help smokers. When TAPP began, 60 to 90 percent were injecting, she said. Now, 10 percent of users are injectors, while the rest are smokers.
“Smokers want in, too, and the Tanzanian president wants to upscale the program around the country for everyone,” she said. “In 2014, I worked on a policy document with Tanzanian colleagues to show how that would work and how it would go through the Ministry of Health.”
McCurdy also recently received a Fulbright Scholarship to follow people in recovery through March 2017. Meanwhile, other countries in Africa are looking at TAPP as a model program for starting their own clinics.
Becoming integrated into the fabric of local communities was a common thread among the Texas Medical Center global programs. These are not one-off trips—to be impactful, they must be in for the long haul.
That commitment is embodied by BIPAI, the oldest of these four programs. Twenty years in, BIPAI has grown significantly from the orphanage-turned-clinic in Constanta, Romania, though that first clinic is still operational.
In an auditorium packed with young, eager medical students, the next generation waiting in the wings to affect global change, Kline summed up the feeling he had when he first saw success in the developing world—a feeling shared by the globally minded across the medical center.
“The experience was nothing short of addictive,” he said. “When you see little stunted, wasted children begin to grow tall, put weight back on, go to school. Once you have that experience, you want to do it over and over and over again.”
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