October 31, 2006 at 7:59 am (Lee's Posts)

My job has been quite interesting, challenging and filled with opportunities for learning. There is quite a steep learning curve due to all the policies and acronyms and government bodies that we work with. Unfortunately, I have yet to go for a site visit to the rural provinces to see HIV+ adults and children who are benefiting from the work we’re doing in trying to get them ARV medicines cheaply. But feeling fulfilled by my work is too much to expect in 3 weeks anyway.


Oh, yeah, the basics. I am working for the Clinton Foundation HIV/AIDS Initiative, whose Cambodia office consists of my boss Alex and me. We work inside of the National Center for HIV/AIDS, Dermatology, and STIs (NCHADS) in Phnom Penh. NCHADS is a body of the Ministry of Health (MoH)—really, a whole lot of acronyms. My title is “Cambodia Country Analyst” and I just got business cards made—my first ever! I work in a small room near my boss’ front room; that’s where there was a free desk. Sharing the office with me is Sonyouth, a fun 26-year-old Cambodian who works on Data Management (he majored in Computer Science) and is studying for his MBA. Also in the office about half the time is Nicole Seguy, a middle-aged French woman from the WHO who (haha) is assisting NCHADS with scaling-up treatment and establishing a more efficient data management system.


My first project was to create a poster to visually demonstrate the linkages that need to be made in the Cambodian health system between the Prevention of Mother-to-Child Transmission (PMTCT), pediatric AIDS care, and early diagnostic services like the co-treatment of opportunistic infections (OIs). My first draft of it was apparently too complicated, though graphically easy to follow. The director of NCHADS, Dr. Mean-Chhi Vun, told me to keep it simple (stupid!) and include cartoons, because Cambodians love cartoons.


Essentially, there was an initial crevasse in our communication—I had thought the poster was to train doctors and nurses, but Dr. Vun had wanted it to be accessible mostly to community health workers and the general public (it will be translated into Khmer and available in both languages). He told me that Drs and nurses can read about the exact procedures in a government policy, but that community health workers who only had a minute to glance and learn about the system of referrals needed something bold and simple, something that grabbed them. The project was a great learning experience, both in terms of integrating policy into visual substance, and in terms of better understanding my audience and the needs and structure of the Cambodian health system.

Here’s the complicated poster:


Complicated Poster



And the simple one:





My most challenging project so far has been to write, almost single-handedly, Standard Operating Procedures (SOP) for a government-based coordinating mechanism to implement social care for orphans and vulnerable children (OVC—again with the acronyms). Essentially, I had 2.5 days to draft national policy about something I knew nothing about at the beginning of that first day. We had an initial meeting with members of NGOs working on social care with OVC, namely, Save the Children Australia, UNICEF, New Hope for Cambodian Children (a local NGO run by an American) and members of NCHADS’ AIDS Care unit who specialize in Pediatric AIDS Care. After the meeting, and an initial meeting with the director of NCHADS, Dr. Vun, I set off to read about 300 pages of policy and reports given to me by the meeting attendees. I had one day to read all this, take notes, and then I began writing the next day.


I received a lot of positive feedback from all stakeholders in the draft process—we had two more consultations with the NGOs listed above and I met with Dr. Vun, who told me what needed to be added and changed according to his vision of NCHADS role in providing the mechanism for social care (rather than implementing it themselves).


So the content of the SOP—NCHADS does not have the funds to provide nutritional support, transport subsidies for medical purposes, and educational subsidies (mainly for supplies, because education is supposed to be free impoverished children) for all HIV+ children, much less all OVC in the country. However, Dr. Vun understood that there was a lack of coordination among NGOs operating in the same provinces and districts, and that as a result many funds were wasted and many OVC were not identified (because of the great fear of many NGO funders who require that grants to demonstrate how a project is original and does not overlap with anything currently being implemented).


At the same time, NCHADS will ensure psychosocial support for OVC in the form of peer support groups that meet on the same day as the peer support groups they already set up for HIV+ adults. They will provide funding for these groups.


NCHADS wishes to create the coordinating mechanism for all operations pertaining to social and medical care for OVC, basically providing fora to discuss successful and unsuccessful procedures in order to implement the most effective models in each district. Essentially, the coordinating mechanism model seeks to create flexibility at the local level rather than dictating national policies that must be followed.


The SOP first lists the services that must be included in a Standard Minimum Basket of Social Care for OVC—psychosocial, nutritional, educational, and transport support (recognizing that other essential services like sustainable local socioeconomic projects, adequate shelter, etc are vital but could not be included in the SOP). The SOP creates the mechanisms for meeting at the district level (there are at least 3 districts in each of Cambodia’s 24 provinces) and delineating who should attend the meetings. Allowing for flexibility, these members include Directors of local hospitals, the Head HIV/AIDS officer of the district, the provincial officers from the ministry of education and the ministry of social affairs, reps of NGOs operating in the district, People Living with HIV/AIDS (PLHA), coordinators of peer support groups, and others.


The SOP describes a community-based model for identifying OVC and providing them with social care services. A model centered on pagodas has been very effective across Cambodia. Essentially, the NGOs we consulted with, as well as NCHADS, believe that, rather than create new institutions, the institution most ingrained and established in local Cambodian life—the pagoda—can and, where possible, should be utilized to help the surrounding community. Of course, this model misses certain sectors of the population, and the SOP describes a similar but secular model for performing these tasks.


The Pagoda-Based System:

· Monks, once trained as advocates, spend time visiting communities, identifying OVC—most of whom are in non-residential care settings such as family care, child-headed households, kinship care, community foster care, etc—and talking about HIV/AIDS treatment and prevention.

· Each monk working on the OVC support group shall oversee one neighboring village, depending on its size—monks can successfully conduct OVC identification and social care visits for 15-30 OVC.

· NGOs and donors shall facilitate training, and throughout the identification process, monks shall work with NGOs and donors to map each village under their jurisdiction.

· After establishing presence in the community, village chiefs often assist the reporting of additional OVC to monks.

· Each pagoda calls for practical and supportive responses to care for the children affected, as well as for the communities from which they come. The pagoda assesses separately the needs of individual children and their families.

· The pagoda works with NGOs and donors to provide material and emotional support to these children.


All in all, it’s an innovative and interesting approach to community-based support. There are still many problems, like the gap of trust that exists between HIV+ women and male monks. In this situation, the women often choose not to disclose their HIV+ status to monks, which may reduce the support they and their children receive. Resourceful strategies for building trust at the local level are still needed, and the hope is that the coordinating meetings between relevant stakeholders might generate some of these strategies.


Finally, the SOP delineates the exact procedure and chain-of-communication for connecting the identification of OVC with voluntary HIV testing for many different sectors engaged in work with OVC and HIV/AIDS (NGOs, orphanages, pagodas/faith-based organizations, schools, PMTCT centers, Home-Based Care (HBC) teams, adult peer support groups for PLHAs, and the child protection network). The need for this is obvious—while overall prevalence of HIV in the Cambodian population is estimated at 2%, the estimated level for orphans is 10%+. Basically, these children need to get tested to know their status, to receive immediate HIV education, to learn important preventative measures which have shown to have efficacy in Cambodia (95% of brothel-based sex workers now use condoms, and the overall rate of condom use has increased greatly), and, most importantly, to begin the process of accessing treatment.


The job is quite interesting, and I feel an immediacy to my work, that it might be useful to the people I am writing for/about. I think this is what has driven me to explore public health and global health in general. This immediacy is something that I definitely did not feel while writing my thesis last year in my carrel at Brown, even as I was writing about people I lived with and cared about.


The one thing that most bothered me, however, is that they assigned ME, of all people, to write the SOP. Clearly they value the quality of my writing, but to assign the person who has spent 1 week in the country and has never worked in a healthcare or policy setting to write the SOP—this just seemed ludicrous and irresponsible. I’m sure that if I had gotten off track, they would have told me, and the revisions suggested by Dr. Vun served that purpose.


On the upside, completing the project gave me the opportunity to read about many policies of NCHADS and to learn about a variety issues and multi-sectoral responses to social care, pediatric HIV/AIDS care, the overall status HIV/AIDS care in Cambodia, and the status of OVC here.


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The Public Hospital, Part 3 or, Ah, Sustainability

October 30, 2006 at 2:15 am (Michael's Posts)

At long last, the screening project I am working on at County is underway  (see past posts on the Public Hospital for an outline). I’m starting to work with two attendings in the outpatient clinic who are hip to the project’s aims of providing more information to docs about their patients’ mental health and substance use patterns.  Definitely fun and I’m looking forward to expanding my interviews to other doctors’ patients.
It’s absolutely two different things to talk about doing “depression screening” and “alcohol screening” and actually asking people about their emotional state and drinking habits. I haven’t seen that many people yet, but I have already had a good number of people admit to me, at times tearfully, that they are “hopeless” most days of the week. When I hear about the economic circumstances they survive from day to day, I am increasingly sure that I might feel hopeless in their stead as well. Is medication the way to get at their hopelessness? They might blunt the pain a little bit, thus causing the symtoms to subside, but they cannot disappear because the root is still deep in them.  Psychoanalytic counseling probably won’t alleviate their suffering. This is why I am an economic radical. There may be socioeconomic solutions that would reach farther than any band-aid that medication could place on this deep, festering wound.  I am on the lookout for them, as I believe we all should be.
The really sad part for me has been hearing the truth that this project will likely be as short-lived as my year of volunteer service. Even if they were to get a grant, the project wouldn’t continue for more than a few years because grants for things like this run out and aren’t renewed. The project should be sustainable in order to have the best effect because the screening is all well and good but the follow-up is the important thing. I don’t know whether that’s the job of the screener (whoever that is) to do follow-up or if it’s the job of the docs to take the green light from the info we give them and follow up with their own patients. But with the great strain already placed on the time and energy of the attendings at the clinic, the project’s creators have limited faith that doctors will be willing to take up the cause. They already have enough on their plates. The two docs I am working with now hope that being able to reach their patients just a little bit better will make it worth it to the doctors to continue the process I begin. Hopefully this is not unrealistically optimistic.  Then the only trouble is finding someone after I leave to continue starting the process.  Or teaching the doctors how to start it themselves.  But then the issue of time restraints… It’ll be interesting to see how this unfolds.

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The epidemic of violence

October 28, 2006 at 2:54 am (Sarah's Posts)

Traffic riots

This article appeared in yesterday’s paper. This is not the first time that I’ve heard of mobs responding to traffic accidents. Unfortunately, it seems to be the case that often individuals take justice into their own hands and exact violence on the person who caused the traffic accident. This happens frequently enough that I read about it in a book about Mumbai and all my friends here acknowledge that it happens, particularly in bigger cities, and particularly when it involves someone from the slums or lower classes.

It got me thinking about violence and how it is related to the health of the community.  This sort of mob mentality happens as the community around them victim surges up to find some justice. Does it happen because the justice system here is slow and ineffectual, so people are trying to find some sort of order? Is it a result of people who don’t normally have a voice trying to make their needs heard? Or perhaps just their anger heard? Is there a way to channel that energy into something that isn’t so destructive?

Loosely related to health, but it has been swimming in my brain for the last day.

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Regarding Gender Mortality in India

October 27, 2006 at 2:24 pm (Links, Sam's Posts)

I realize I often resort to asking about/talking about interesting articles instead of posting solely based on physical experience or mental pondering.

Nonetheless. I decided today that I should take advantage of my automatic access to just about any journal I want.

Excess Female Mortality in India

Now, this article is from 2000, so the numbers have definitely changed. But the problem is still the same.

In particular I wonder whether or not the state of decline in female:male ratios that existed in 90s still exists. Do males still (allegedly) benefit more from nutritional and health advancement? I wish the author didn’t glaze over the reasons for uneven populations of men and women – “While the reasons for India’s anomalous sex ratio are fairly well established…” – but the examination of Himachal Pradesh seems like it might have a lot of potential. And it’s inspiring that something as concrete as literacy rates could explain an increase in female:male ratios; to me the improvement literacy rates seems a lot more doable, while also not being something that I would have thought of on my own.  I’ll have to look for publications involving further research into Himachal Pradesh.


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Inspiring people to think to the future

October 21, 2006 at 1:57 am (Sarah's Posts)

I’ve seen lots of tremendously inspiring examples about how public health folks have gone into communities, identified a need and gone to all sorts of lengths to convince people to change their behaviors in order to ameliorate the problem. The behavioral change is often the most difficult part, which is what has been on my mind lately.

I can come up with lots of methods to motivate people to rally around an issue. You can give them the reasons why it will help, offer incentives, use logos, pathos and ethos to convince them that they should be invested in the problem. But, it strikes me that our end goal shouldn’t be just to convince people to wash their clothes far away from their drinking water source or to get their babies immunized. If communities are really to develop, they need to have a sense of responsibility and ownership of the whole process. They have to be willing and able to look around at their world, target the problems and then work to fix them. At the end of the day, it is their community and they know the problems that face them better than any outsider. In the best model, it seems to me that the public health or development worker wants to eliminate the need for his job by building people’s capacity and interest to deal with community problems as they arise.

But, I’m having trouble with the idea of how to motivate this sort of mind frame. There are so many issues that take up people’s time. When I look at how hard, for example, a rural woman in India has to work just to prepare three meals, boil water, find fuel, deal with family and keep a house, I slightly guilty for asking her to work on a larger scale when the tasks in front of her are so energy and time consuming. How do you get people to look forward into the future when the present isn’t terribly certain?

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Therapeutic Gene Product Delivery

October 19, 2006 at 1:11 pm (Links)

Sarah and I have been talking about hemophilia treatment, among other things. This file has 3 abstracts and a review that I took from the Internet. I worked for this guy for a year, he’s good. See the conversation between Sarah and me under the post ‘Sex Selection’ for more background.


In particular, check out part 4 of the review, entiteld ‘Bioengineered Striated Muscle for Therapeutic Delivery of Gene Product’. Turns out you can make little muscles that release a therapeutic protein of your choosing and implant it into a mouse to see if it works consistently.

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Sex selection

October 15, 2006 at 4:26 am (Sarah's Posts)

Since the passage of the 1994 Prohibition of Sex Selection Act, it has been illegal in India for medical personnel to use any sort of diagnostic tool to determine the sex of a fetus. This is in response to a frightening data set that shows that there are many fewer female children being born than male children; because of a strong cultural preference for males, it wasn’t uncommon for couples to abort a pregnancy if it was to be a female child. I found the child sex ratio numbers (number of girls born/number of boys born*1000) staggering. From just a few states in India, they are Punjab (793), Haryana (820), Gujarat (879), Maharashta (917), Kerala (963). Even more disheartening, the numbers are actually declining. My prof explained that there is a lot more pressure now in India to have fewer children. When you only have two kids, it gives you fewer chances to have a boy, so there is more pressure to terminate a pregnancy if you can tell that it will be female child. So, the gov’t made it illegal to determine the sex of a child before birth.

So now, my prof and several senior students in the department have designed a genetic test that measures whether an unborn child has the genes for hemophilia. The problem is that hemophilia is a sex-linked disease—only men get it while women can be carriers. The gov’t doesn’t want to allow this test because it determines the sex of the child. They have proposed that the standard of care should be to only administer the test to people who have a genetic history of hemophilia. They would only find out if the woman were carrying a male fetus that was positive for hemophilia. If the child was a female carrier, that information would not be disclosed and would only be considered when the girl was grown and planning to have her own children.

One more story about how complicated policy can get when we take into account the cultural backdrop. For now, I’m going to keep my editorial comments to myself for the moment because I’d like to hear what other folks think when they hear about this.

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The Thing About the USA

October 13, 2006 at 5:02 pm (Michael's Posts)

We all know that health disparities exist in the United States as well as abroad. We know it in our heads, that is. Of course there are poor people here and they must be at greater risk for threatened health than the non-poor (to borrow a Farmer-ism). This is something we can deduce from the knowledge that there are poor people in the US and that the poor are vulnerable.

But can you visualize poor Americans? I mean really hard-luck folks whose reality is so different from our own? Like Third World different? Often, it’s hard to see the sunken cheeks associated with poverty and hunger that haunt our own urban centers because (I assume) many of us don’t associate basic resource dearth with the idea of Home. But here I sit in the Public Library in downtown Chicago. And across from me is a man in his thirties coughing like a TB patient with eyes as big as the hungry I saw in Delhi. He’s got a coat on, but it’s dirty and worn and destitution is obviously his reality. If I hadn’t been sitting down to write a post for the blog on the health-threatened in America, would I have noticed him? I fear I might not have.

I’ve been thinking lately (spurred by some questions I was asked in my interview at UChicago med) about health disparities in our own country. Global must include our Home, too. We have to remember to always be open to what is going on here, where most of us have the greatest expertise and most number of connections to resources. I think the question is how to locate the inequalities. Obviously, there are more Absolutely Poor people in “developing” countries, but there are millions of Comparatively Poor in the United States who we must not neglect.

Discuss. 🙂


ps- sorry I’ve been AWOL. Moving is a crazy endeavor.

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cheesesteaks and chili fries

October 11, 2006 at 4:47 pm (Links, Sam's Posts)

I don’t how my current city of residence, Philadelphia, would ever be able to mimic what might happen in New York City and Chicago, among other places.

New York City Plans Limits on Restaurants’ Use of Trans Fats

Seems pretty cool that the New York Board of Health can go ahead with legislation like this without much bureaucracy or red tape to bust through. I don’t want to speak too soon, of course.

 I’m pretty sure you can register on for free, so don’t complain that you need to log in to view this article. I feel like I’m breaking copyright laws when I copy and paste articles into word and post them on the web.

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High throughput medicine and mopping up polio

October 8, 2006 at 2:39 am (Sarah's Posts)

I had the tremendous opportunity to observe a Rotary International sponsored polio corrective surgery camp yesterday. Although the number of cases of active polio has gone down quite a bit due to a worldwide vaccination campaign, there are still folks who are disabled from previous infections, with the classic manifestation being paralysis in the limbs, such that they appear shriveled and lose some/all functionality.

This particular project is a two day camp where six orthopedic surgeons perform about fifty surgeries to correct the disabilities that come with previous polio infection. When we first arrived, there was an hour and a half ‘inauguration.’ Normally, I have zero tolerance for the sort of events where ten people get up and talk to hear themselves speak and flowers are given out and everyone claps. They strike me as self congratulatory and my impatience stems from the fact that it is nearly a cardinal sin in the US to waste someone’s time. Luckily for the sake of my patience, I got a good explanation for it this time around. The camp was being conducted at a Primary Health Center, which is a government run hospital that serves the rural community. In a sense, listening to the pomp and circumstance is a tradeoff—the Rotarians get the hospital for free, which would have been prohibitively expensive had they needed to find a way to work it out on their own. It was a good reminder to me that politicking and networking are an important part of being able to deliver healthcare. Sometimes I get my eye on the prize and can’t stand the details that prevent me from doing work, work, work.

Most of my time was spent with the first doc that the patient’s saw—the triage doc. The triage process itself was fascinating. Firstly, he’d look at the level of deformity to see if there was anything that surgery could do. But, there was also a practical evaluation. He would ask what they did for a living, and if they could still work with their deformity. No elective procedures here—sheer functionality. The evaluation took about a minute total, and he would give them the outcome—surgery or none. There is no real question of things like physical therapy, although they moved mountains to get one girl some rehabilitive care. You could see the look of disappointment in the eyes of the people who were told that surgery wasn’t possible. The power that this doctor had to pronounce the patient’s future frighteningly godlike. At the same time, he had a down-to-earth humanity about him that was truly beautiful. We would never be able to tell a patient, “You need to be happy with what you’ve been given, because you’ve achieved a lot by being able to walk in the first place.”

It brings up a lot of questions for me about how to best administer care under the high-throughput conditions of a camp like this. It is truly amazing that they can administer to so many people in a short time. We focus so much of our medical care on how to talk to patients, how to deliver difficult messages, how to make the patient feel good about whatever you can do for them. You sacrifice some of these things when you can only give one minute of assessment and care to a patient. It also strikes me that there is a greater degree of distance between the patients and doctors here. Many people are extremely health literate at home, thanks to the internet and the accessibility of health information. Here, the information gap between the patient and doctor is often much wider, so his word is absolute.

Still, they are doing amazing work and touching many people’s lives. It makes me extremely grateful that there are folks out there who are willing to take on these projects with their time and energy. Beautiful inspiration. A few pPhotos at my flickr account, which is under SarahLynnKimball.

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