Eric Lakomek ’21– This summer I have had the pleasure to participate in an Immersive Learning experience funded by the Wabash Global Health Initiative with alumnus Dr. Sean Sharma ’98 and the staff at the Fountain and Warren County health departments. I was given the opportunity to experience the outreach of public health in the only bi-county health department in the state of Indiana.

Dr. Sharma, left, and Eric Lakomek

The principal task I spent most of my time on this summer was developing an open-ended project that addressed a major health care need in the community that would have a lasting impact on the residents for years to come. After searching through many recent demographics of the area, I decided to develop a project to combat the mental health crisis facing both Fountain and Warren counties.

Nearly one in five people in both counties are affected by depression and anxiety. In Fountain County, 15 methamphetamine labs were seized in 2013, and both counties have an extremely high drug overdose rate. However, the ratio of mental health and addiction care providers in Fountain County was 2,082:1. These statistics helped demonstrate a serious problem that desperately needed to be addressed in this extremely underserved area.

For the little help residents do receive, the rapid ascent of mental health illness and substance abuse diagnoses is not coupled with an accelerated awareness of resources available to the community. In addition, the stigma surrounding mental health must be reduced so that those who need help are more willing to seek it.

I created a series of posts and articles detailing the many different disorders, common symptoms, and where to seek treatment, as well as a list of around 50 immediate and professional resources within 50 miles of the health department. I also called different locations of treatment facilities and attempted to find out the average wait times and what to expect to make things more transparent. This made me realize the difficulties an individual goes through just to get in the door of these treatment facilities.

Often times, individuals can not receive the proper treatment they need because of the lack of access to care and governmental funding. What I observed this summer has allowed me to put my liberal arts education to use and apply it to addressing the behavioral needs of the community. Mental health is not a clear-cut subject. Each person has a different story and viewing it from different perspectives has allowed me to understand a completely diverse side of this growing topic.

I am excited to use what I have learned and look forward to using it to make the mental health process easier to navigate in the future. There is a growing crisis in America today, but as I have learned, there still a reason to keep on fighting the stigma. Many groups today are working on moving mental health to the forefront of healthcare problems that must be addressed. Thank you to all who have made this internship possible!

Matthew Hodges ’19 – As a pre-med student with a primary care focus, I tend to frame preventive care at an individual level. When I think of preventive health measures, I generally think of proper diet, adequate physical exercise, reducing high-risk behaviors, and receiving routine checkups, vaccinations, and examinations. While these factors are undoubtedly important and play a key role in public health, there are so many preventive measures beyond the scope of individual lifestyle choices that are absolutely vital to a healthy community. Working at the Montgomery County Health Department this summer, I’ve had the opportunity to see a small fraction of the work that goes on behind the scenes to keep our community healthy.

Matt Hodges ’19 laughs during a day of picking up mosquitos.

Many of the health department’s responsibilities are things that we don’t think about; we simply take them for granted because they have been done so well for such a long time. Food inspection and sanitation specifically come to mind. When we sit down at a local restaurant and order our favorite menu item, we assume the food is clean and won’t make us sick. When we look down at our plate, we generally don’t ask ourselves at what temperature the meat was cooked, whether or not there was cross-contamination in the kitchen, if everyone was wearing a hairnet, or if the freezer was cold enough. Fortunately, Adrianne Northcutt has already asked all of these questions so we don’t have to. Similarly, the whole appeal of indoor plumbing is that we don’t have to think about what happens after we flush. That isn’t magic – it’s a man named Don Orr. Don personally inspects every septic system in the county to make sure they meet standards that prevent a whole host of unpleasant sewage-related problems.

Without people like Adrianne and Don, it would only be a matter of time before diseases and health issues that primarily exist in history books and developing countries come back to bite us. Working at the health department, I’ve learned the importance of a sound, well-regulated infrastructure. Many of the societal comforts we take for granted are in fact substantial victories for public health.

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.

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.

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.

Unfortunately, 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.

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.

Meningitis 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.

Bilal Jawed ’17 – It didn’t hit me when I first got the news in the spring. It didn’t hit me the weeks leading up to the flight. It didn’t even hit me when I stepped onto Ugandan soil for the first time and rode to my apartment in the late hours of the night after a long two-day journey. But this morning, precisely at sunrise, that’s when it hit me. That is when I realized I would be spending my entire summer in Kampala, Uganda. I awoke to a certain cocktail of sounds that affirmed that I was 7700 miles from Crawfordsville. The Adhan, the Muslim call to prayer at sunrise could be heard from a nearby mosque, monkeys howling from treetops, a baby crying in the next door complex, and the fan blowing against the mosquito netting covering my bed that protects from Malaria.

It was certainly daunting and awe inspiring at the same time. will certainly be challenges in adjusting to life in Kampala, both big and small. Its always tough knowing your family and friends are just going to bed as you are waking up or knowing fast internet speeds are a luxury of the past (I definitely will never complain to the Wabash IT department ever again). The package includes no air conditioning, lots of traffic, and frequent power outages, and a myriad of other adjustments, but anything can be seen as an adventure in an appropriate light. The ground is red, the people are very friendly, and I am ready to get to work. More to come about working day to day with HIV patients in Mulago Hospital!