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Jawed ’17 ‘Final Pills, Final Thoughts’

Bilal Jawed ’17 – When I woke up that very first morning in Uganda, I had 87 pills of doxycycline packed away for malaria prophylaxis –one for each day in Uganda. It’s been a pure, raw, and emotional journey watching those pills disappear, day by day, pill by pill. As I swallow #87 today, I would be lying if I said I was the same person at #1. Each pill has its own taste, some sweet, others sour. It’s difficult not to reflect while holding an empty prescription bottle for the first time. A few come to mind. #2: my first day on the ward. Words and pictures will never represent the suffering and sadness adequately. #15: discovering that Mulago has a private ward for paying patients. I remember the frustration of learning how much of a difference a few dollars a day can make. #30: visiting the ward after dark to finish up some work from the day. I will never forget the overwhelming experience of swarms of people coming up to me, requesting medication and medical attention. Sick people remain sick even when the doctors go home. #73: sitting down to discuss a patient only to realize that there is almost nothing we could do to treat his disease (at the time he was thought to have a condition called ICL).

Spending a holiday in the home of a good friend.

Spending a holiday in the home of a good friend.

While it is so very easy to reflect on the bad, discuss the bad, and even blog about the bad, the bad will not be what I take away from Uganda and will certainly not be what I will remember in the years to come. I will remember the people. I will remember the doctors who don’t bat an eye when work and life begin to blend. I will remember the nurse, who despite being pulled out of retirement may be one of the hardest working people I know. I will remember the lab phlebotomist who spends his day running back and forth from lab to lab to give the most up to date results, and possibly save a life. I will remember the HIV counselor who fearlessly combats years of dense misconceptions and stigma day after day without falter. I will remember the friendly Ugandans –I never once regretted starting a conversation with a stranger.

I’ll end by being honest. I am not sure how the average American can help the sick people of Uganda or if they even need our help in the first place. The issues there are infinitely more complex than just sickness. Ellen Einterz summarizes it best, “It is probably possible to fill a well by pouring water from above, but better in the long run to dig deeper and let water rise from below.” Education, stronger structures, cheaper drugs, and sanitation will always be the answers. While Africa and Uganda may be a long plane ride away (I can attest to this), we as Americans in a shrinking world are not so far away. While the majority of the world will never see the poverty in those wards first hand, the poverty is certainly there and it is very close to us. This experience has absolutely shrunk my view of the world. It has distorted and altered my view of what health is, and what it means to be a health care provider. For the rest of my life, I will always carry a slight tinge of responsibility to share the stories found in Uganda –to serve as a reminder to the other 99% of the world that will never see a Ugandan ward.

Finally, no story is complete without its thank-yous. I would like to extend an extremely deep thank you to Dr. David Boulware for opening up his project and world to me. I am always astounded by all of his work. I would also like to thank Dr. Wetzel, Mrs. Rogers, and the Global Health Initiative for making this all possible. Lastly, I would like to thank Dr. Rhein, Ms. Williams, and the entire ASTRO team for being so welcoming to their work, their lives, and for some, their country.


Jawed ’17: Both Sides Now

Both Sides Now

Today I stood and watched a man die – the life leaving his body right before my eyes. His struggle for breath became harsher and harsher until an abrupt silence fell. The immediate cause of death was asphyxiation; he literally suffocated to death in front of his loved ones. The mother sobbed on my shoulder. After a few moments we went our separate ways.

What shook me was how quickly his bed was replaced. Within 5 minutes his face was covered with a blanket and the bed carted out only to be replaced by another sick individual in the already overflowing ward. In moments like this, I look to our team physicians to see how to react. Despite witnessing sad final moments of a sick man, what equally shook me was the apathy towards death seen in the medical professionals; it seemed almost casual. The team noted his death and methodically moved on to the next patient as if he had only fallen asleep.

At times it is easy to see these physicians as cold. After some time and thoughtful discussion with our physicians, however, I believe this appearance comes not from a disregard for patient life but rather an understanding. Our physicians understand that they are only a quick blip in their patient’s lives. They understand that they are simply the final stop for these patients after years of poverty, sickness, and societal failures.

The medical system in Uganda failed our patient in two ways. First within immediate care facilities; Mulago Hospital only has a handful of ventilators for its hundreds of patients. Because ventilators are scarce, physicians are forced to decide which patients are able to use the equipment based on their condition. Unfortunately for our patient, medical officers decided that his chance of survival was too low to justify use of the ventilator; he would take away from another patient who would have a better chance. The second failure is significantly more intricate. While our patient’s immediate cause of death was asphyxiation, his underlying causes were opportunistic infections contracted from being HIV+. If he simply took his HIV medications, he would be significantly less likely to contract diseases like cryptococcal meningitis or tuberculosis and would likely live a long and healthy life. Exactly where the health system failed him is difficult to pinpoint. Was it a lack of medication adherence and follow up by physicians? Was it the lack of availability and accessibility of antiretroviral drugs? Or perhaps it was even earlier with lack of counseling on safe sex practices that allowed him to contract HIV in the first place? Structures are crumbling not from just the top but from the core foundation.

1434980435890bUnfortunately, these stories are a commonplace and can take a toll. Being around so much sickness and death often makes you forget about the other side. After this particularly long day, I dragged myself back to the office from the ward. In the tunnel connecting the two, a man stopped me. It isn’t uncommon to be halted in the labyrinth of Mulago Hospital by people needing directions. Not knowing the hospital very well, I instinctively began to lead him to the office where he could receive better directions. I quickly stopped when he asked me something that caught me off guard. He asked me if I remembered him. It was Kasim! Kasim was a patient we discharged a few weeks back who presented with severe confusion from cryptococcal meningitis and seizures. I was barely able to recognize him as he was standing, smiling, speaking clearly, and wearing his nice clothes – conditions I had never seen him in. I will never forget what he said next: “You saved us, you saved us!” We shook hands and even got a picture together. Even though I had a minute role in his recovery, that moment changed how I thought about many aspects of healthcare. I returned to my desk with a big smile and a different point of view. I have no doubt that my few moments with Kasim will remain the highlight of my experience in Uganda.

I juxtapose these two patients for contrast but not at all to reconcile the ups and downs. The success stories remain independent of the failures. Each day has its unique combination of joy, sadness, challenge, frustration, and success. I would have it no other way.


Jawed ’17 Continues Research in Uganda

Sertraline, Sickness, and Stigma: Conducting a Clinical Drug Trial in Uganda

What does Zoloft (Sertraline), a prescription anti-depressant you may have seen commercials for in between Jeopardy rounds, have to do with people suffering from meningitis in Uganda? Much more than you would think.

In collaboration between the University of Minnesota and several Ugandan medical organizations, the clinical drug study dubbed the A.S.T.R.O. study (Adjunctive Sertraline Treatment for Cryptococcal Meningitis) hopes to find new and more accessible means to treat patients with Cryptococcal Meningitis in low income areas. Sertraline is commonly used as an SSRI antidepressant in the United States but is known to have anti-fungal properties, which leads to the study’s hypothesis that adjunctive Sertraline will lead to faster fungal clearance and an improved 18-week survival rate.

GlobalHealthMeningitis is a debilitating acute inflammation of the brain and Cryptococcal Meningitis (crypto for short) is a specific type of meningitis caused by the fungus Cryptococcus neoformans. Crypto cripples impoverished Africa as it rivals TB in mortality in the area. To put it in perspective, I see more cases of crypto in a day than 99% of American doctors will see in a lifetime. Well over half of individuals with Cryptococcal Meningitis will die within 10 weeks if not given proper treatment. While the study is certainly combating Meningitis, it remains only a symptom of a much larger and more serious HIV epidemic. Nearly every single patient the study has seen with crypto has been HIV positive. With HIV comes an entirely new set of challenges including stigma, misconception, and a severe lack of education. The ASTRO team fights not only the illness but also the stigmatized mindset behind many of these diseases. Patients attend weekly classes on treatment and receive HIV counseling. Nonetheless, the stigma is still present. Very often, wives who bring in their husbands infected with HIV/crypto ask to be HIV tested. If the discover themselves to be HIV negative, they often abandon their husbands in the hospital mid-treatment never to be seen again.

The day begins with the ASTRO team meeting. Team doctors, nurses, lab scientists, councilors, and everyone else who make the study possible meet every morning to develop a plan for the day and review the patients enrolled in the trial. Fortunately, if an individual is eligible for the ASTRO study, he or she will receive significantly more attention and better care from our team who fully treat the patient’s issues, not just the crypto. This includes paying for additional medications, CT scans, labs, and more. Unfortunately for the patient, to be enrolled in the study, he or she is likely very, very, sick. After the team meeting, we head down to the Ward and doctors treat every patient individually. A central component of treatment in this study is the lumbar puncture, which I am often responsible in aiding the physicians to conduct. High intracranial pressures are a result of the fungal inflammation leading to symptoms such as stiff necks and headaches. To relieve pressure, the ASTRO team conducts lumbar punctures which are spinal taps to remove cerebrospinal fluid. Spinal taps are vital in treatment for crypto but patients often decline, having developed an association between the procedure and death. To combat this negative association, Nathan Yueh, a friend and student formerly involved with the ASTRO study directed the short film Mulalama (Taking Water). The film follows the struggles of Maria, a young woman that consents to a lumbar puncture for her ill mother despite her fears. The film takes place in our very own Mulago Hospital and I highly recommend a watch. View it here: https://www.youtube.com/watch?v=dVqyj4sgDDA.

Following clinical rounds, the second half of my day is spent recording and analyzing patient charts. As an international clinical drug trial, there is a significant amount of communication and paperwork required both within the study team and also to IRBs. Data is key. Collecting hemoglobin information may appear to be irrelevant in a drug trial for Sertraline but it may contain enough information to spark an entirely new study.

The days can be long and the work somehow follows you home. I admire the Americans who brought their entire lives here to study infectious disease just like I admire the Ugandans who work grueling hours when they likely could be making much more practicing in a private hospital. I feel as if everyone on the study team has a reason to be here. This experience is bringing me closer to unraveling why I need to be here, whether “here” is Uganda, Peru, or Crawfordsville.


Beyond Belize’s Beaches: A Wally’s attempt to peer into the world of global health

Warm wishes from Belize!

My name is Luke Wren and I graduated from Wabash last May as part of the class of 2014. I am currently typing this on a sunny cement balcony in the northern part of Belize, in a small town called Orange Walk. When many people hear “Belize” they see visions of vast oceanside, images of colorful fish shimmering in the water, or a coconut tree shedding its hard-shelled goodness. However, Belize is much more then simply a great place to vacation or prime real estate for wealthy expats. Belize is a culturally unique place with numerous ethnic groups, and even more small villages full of Belizean culture.

Screen Shot 2015-06-01 at 2.01.06 PMBelize, formally British Honduras, is the youngest country in the western Hemisphere. Although young, Belize has a very rich history and one that dates back for millennia. At one point millions of Mayans lived throughout much of Central America, including Belize.  Mayans form civilized city-states and were much more then simple hut-living indigenous people. They had routes of trade, fought wars, built temples, and created some of the most beautiful monuments (now ruins) in Belize.

Belize is full of wildlife, rivers, caves, mountains, beaches, and cayes. Although rich in biodiversity there are still over 300,000 humans that call Belize home. It is for these Belizeans, especially the impoverished ones among them, that I am here. I am currently in the University of Notre Dame’s Master of Science in Global Health Program, which is a part of the Eck Institute for Global Health. After completing two semesters of classes, I now have the opportunity to complete my capstone project focused on global health.

What drew me into global health? Primarily it was Wabash’s own Dr. Eric Wetzel. Dr. Wetzel provided me the opportunity, along with many of my peers to travel to Peru in the summer of 2012 for two weeks. During this immersion trip we worked alongside doctors, medical students, and veterinary students and helped with conducting local community health clinics. This experience opened my eyes to what medicine the majority of those on Earth have. Most people do not have access to full care hospitals, sanitary environments in which to give birth, or even a “standard” clinical setting to give birth. Many births are done at home or at local health centers. This educational experience did what Dr. Wetzel says our education should do…it disturbed me.

Being disturbed in an educational setting is what takes knowledge and changes it into action. You can read a book about malaria or watch a documentary or series of YouTube videos, but without seeing how Malaria affects people with your own eyes it keeps the information in 2-dimensional space, and thus is very hard to fully understand. Being disturbed by something changes something within and that can be bad at times, but in this case it was positive.

Travelling to Peru, hearing the sounds, smelling the smells, touching things that Peruvians touch, walking where Peruvians walk, took my education to a different level…and it made me sick to my stomach. I will never forget the feeling I had standing on the side of a hill in a slum of Lima, called Pamplona Alta. I look out and see tarps, filth, garbage, disease-ridden dogs…I smell burned trash, burned feces, but most importantly I see homes. People live here. People grow up here. People fall in love here. People grow old here. I have never felt so bad for having so much. All of my petty complaints of my life were dwarfed compared to the daily lives of these Peruvians. I knew I had to change what I wanted to do.

I have always wanted to become a doctor, at least since high school. I still plan on becoming a doctor, but my path to get there and what type of doctor I want to be has changed because of my trip to Peru. I pursued this Masters at Notre Dame not only for the education and experience, but for the opportunity to travel and learn more about resource poor-settings. My goal is to become a rural doctor, focusing on resource poor-settings.

I am in Belize to study Chagas disease, a parasite-caused disease that is transmitted by Triatomine bugs or “kissing bugs”. These bugs contain the parasite in their feces and can transmit the parasite to humans. When humans get infected with the parasite they can have acute symptoms, but not all show signs of acute symptoms and go straight into the chronic phase, which after a period of time (10+ years) a person can have fatal occurrences of heart disease, digestive issues, and damaged organs.

The two aims of my study are to:
1)   Look at the effectiveness of current control strategies like insecticide-treated bed nets, insecticide paints, and indoor residual spray (more insecticide) on the vector.
2)   Survey local heads-of-households in surrounding villages of San Ignacio, Belize. I hope to better understand how much local populations know about Chagas disease, the vector, signs and symptoms, and current control methods with the goal of providing the Belize Ministry of Health this information so they can streamline future directed educational campaigns.

I plan on updating my blog at least once a week, and hopefully with pictures. I will not just talk about research but my experiences, and my thoughts. Please feel free to pass this along to anyone you think might find this interesting.

Here is a link for more information on Chagas Disease: http://www.cdc.gov/parasites/chagas/

That’s all for now,
Luke