My global health journey: a reflection on my time in the field and advice for students and young professionals

By: Kiran Kamble, M.B.B.S., AFIH, MPH, PhD Candidate

After graduating with a medical degree, I started my professional career as a primary care physician in Mumbai, India, where I partnered with Government of India’s Revised National Tuberculosis Control Program (RNTCP) providing free diagnostic and treatment services to my patients suffering from tuberculosis (TB). In many cases, the financial savings these services created for the low-income families made them avoid bankruptcy. This challenging yet tremendously satisfying experience showed me the complementary nature of clinical medicine and public health. Later, when I took up a job at the World Health Organization supporting India’s RNTCP implementation through public private partnerships (PPP), I got to experience the tremendously influential role of the civil society in public health. Working with the not-for-profit and for-profit health and non-health organizations, I experienced first-hand the importance of socio-economic determinants in health policies and programs.

Later, as a consultant, I got the opportunity to work on diverse projects such as developing the bottom-up (from a village level) action plan for India’s national health sector reform initiative, mapping HIV/AIDS high-risk groups to develop focused behavioral interventions for these groups, operationalizing protocols for emergency first responders, evaluating India’s financial voucher scheme for reducing maternal mortality, and conducting a feasibility study to establish super specialty diagnostic centers through PPPs in underserved areas. I learned the crucial role a public health practitioner can play in shaping public health policy and implementation to improve lives.

My first foray into global public health (global health) was as a member of an international team tasked with revising health policies for the Government of Abu Dhabi. I was amazed with the complexity of developing a health policy, let alone implementing it. Stakeholder mapping, understanding, and accommodating demands of different groups, and balancing and prioritizing conflicting needs is as difficult as performing a heart transplant. I also understood how important it is for a public health practitioner to have basic knowledge of certain quantitative and qualitative skills. On learning those tools through an MPH from Harvard University, I got the opportunity to expand my experience in global health by providing consultancies to The Global Fund, various United Nations (UN) organizations, European Union (EU), United States Agency for International Development (USAID), and other global health organizations across 30 countries and counting. Working in fragile nations such as Afghanistan, Central African Republic (CAR), Haiti, Iraq, South Sudan, and Yemen as well as developed countries like Japan and South Korea, gave me insights into different health systems.

My global health experience keeps me grounded when I think of all those ordinary people doing extraordinary tasks that I had the opportunity to learn from. From the Auxiliary Nurse Midwife in a small tribal village in India, who despite being physically assaulted, continued her work of vaccinating children for decades traveling on foot across forests; the Catholic nurses and Ramakrishna Mission priests in Jharkhand, India, who tirelessly provided care to TB and leprosy patients; the community health workers in Iraq and Yemen who risked their lives to ensure availability of HIV, TB, and malaria medicines to hard-to-reach areas; the orthopedic surgeon manning a primary health care center in Afghanistan, working on a meagre salary of $120 per month yet providing free care to the poor; the medical doctor in Guyana who spent after work hours educating people about HIV prevention in his community; the warehouse stock keeper in Haiti who acquired a supply chain management diploma to contribute to strengthening medicine supply in his country; the woman NGO owner in Somali, Ethiopia, who without any technical knowledge or experience, conceptualized a revolving fund system using funds from The Global Fund grant to help people living with HIV establish their own small-scale businesses; the Director of TB Control in Solomon Islands who spent his own funds to travel across the islands to monitor the program; the District Administrator in Oyam, Uganda, who underwent training for malaria control and attended as many village-level camps as he could to motivate his staff; and the Peace Corps volunteers from the United States who get out of their comfort zone to live and work on social projects in the most remote parts in the developing world. There are so many such stories that may never be told but will always inspire me. Besides, COVID-19 has shown us how unavoidably interconnected we are and how important the global health approach is.

So, some of you who want to make a career in global health but wonder how to go about it? Here are my two cents. Most important, in my opinion, is having a passion for public health and acknowledging that it is more than a job. I chose the path of consultancies against a full-time job as I wanted to explore different program areas and it suited my personality better. It is, however, not easy to immediately take a plunge into the world of consultancy. One would need to establish some work experience and build their network. I will give network building a higher level of importance and it should start right from when you are as a student. Try and identify your interest area and reach out to the experts in your field – seeking knowledge of the field and advice on how to maneuver your career path. It is easier said than done but you would be surprised how many would respond to you, provided that you do not put them on the spot by asking for a job recommendation. Use your school faculty and alumni to make such connections and actively use professional networking platforms. Learn what specific skill sets organizations are looking for in your field of interest. Get to know the keywords they look for and try and get those skill sets into your curriculum vitae through the academic route first. At the end I have listed a few resources, apart from your very own APHA membership, that will help you explore global health organizations and jobs.

From my understanding, one of the core requirements in global health, in addition to domain knowledge, is the readiness to travel internationally and relocate, at least initially. The rewards are tremendous personally, academically, professionally, and financially too. Global health will make your friend circle and professional network grow exponentially. And please do not forget the pleasure and honor of interacting with different cultures and learning from them! After having explored a few different career paths myself, medical practice, pharmaceutical manufacturing and retail, and occupational health consulting, I can unequivocally state that there are few other fields like global health that give such breadth and depth of knowledge, exhilaration, soul-satisfaction, and adrenaline rush. Of course, as any other profession, there are risks and stressors, but the benefits certainly outweigh the risks.

A few photos from my global health journey:

Photo Captions
Top Left: Director of National Malaria Program directing his driver through a flooded street in Dushanbe, Tajikistan.
Bottom Left: Hotel constructed from shipping containers in Juba, South Sudan.
Middle: This may just be the world’s smallest pharmacy – in Port-au-Prince, Haiti.
Right: The smallest plane (6-seater) I have ever traveled in. The pilot asked me to plug a piece of paper in this aperture to keep it open so that air pressure inside the cabin was maintained– Solomon Islands.

Global Health Resources

https://www.fic.nih.gov/Global/Pages/NGOs.aspx, https://www.albany.edu/globalhealth/organizations-working-global-health, https://sph.umich.edu/global/non-governmental-orgs.html; https://ocs.fas.harvard.edu/explore-careers/global-health; https://www.who.int/emergencies/partners/non-governmental-organizations; https://www.tephinet.org/global-health-and-international-nonprofit-organization-websites; http://www.imva.org/Pages/orgfrm.htm;

Empowering Women to Take Control of their Sexual Health

Two weeks ago, I attended a powerful and motivating summit hosted by Florida International University (FIU) Robert Stempel College of Public Health and Social Work on empowering women to take control of their sexual health through knowledge of biomedical HIV prevention methods, connecting to community resources, and mobilizing key community stakeholders and providers.

What was most unique about this summit was the rawness of the various conversations. These conversations included voices of state congresswoman Frederica Wilson and Ileana Ros-Lehtinen, community women and activists, a panel of diverse physicians and nurse practitioners, researchers, and LGBT and minority women working across different sectors in the HIV prevention field. When it comes to empowering women surrounding their sexual health, pre-exposure prophylaxis (PrEP) is viewed as the driving vehicle. The problem is that there is a lack of awareness among women particularly LGBT and minority women, and providers about PrEP and post-exposure prophylaxis (PEP). During the engaging providers panel comprised of various physicians working in South Florida, a Haitian physician expressed that before the conference he decided to call several of his provider friends that practice within the local Haitian community and asked them if they have heard of PrEP. How many do you think said, “Of course, I know about PrEP”? The answer is…0. Not one single doctor whom was asked said they have heard of PrEP. We have a lot left to do. The work has not yet been done!

Miami’s HIV Epidemic

So maybe you are wondering…well why host this conference? The county of Miami-Dade continues to lead the nation in new HIV infections. Not too far away is the neighboring county of Broward which continues to compete with Miami when it comes to high prevalence rates as well.

Due to the rising rates of HIV in Miami-Dade County, city officials have responded to the epidemic with the development of a “Getting to Zero” task force comprised of city commissioners and individuals representing various public health agencies throughout Miami-Dade County as well as the state of Florida. The task force devised a multi-pronged action plan with priority goals for the next two years. The plans include to (1) reduce the rates of reported AIDS cases, (2) reduce the percentage of newly diagnosed HIV cases among residents aged 13-19 (3) increase the percentage of newly identified HIV-infected persons who are linked to care within 90 days of diagnosis and are receiving appropriate preventive care and treatment services in Miami-Dade County and (4) reduce the number of newly reported HIV cases in Miami-Dade County (http://www.miamidade.gov/releases/2016-09-29-mayor-getting-to-zero.asp).

Prep around the globe

PrEP has served as a vehicle for prevention and is being used worldwide. Countries such as the United States has large scale PrEP programs while others are still in the stages of development and some have not implemented as of yet. There has been many PrEP initiatives enacted. The US Agency for International Development (USAID) is currently supporting 5 Microbicide Product Introduction Initiative (MPii) projects in Kenya, South Africa, Zimbabwe, Malawi, and Uganda from 2015-2020 focused on gender-based violence, drug resistance, creating demand, introducing new products, and models for delivering services. Another program is the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) initiative, a collaborative effort between US President’s Emergency Plan for AIDS Relief (PEPFAR), Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences and ViiV Healthcare. DREAMS aims to reduce the incidence of HIV by 40% among adolescent girls and young women by 2020 in the highest HIV burden countries including Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Of the 10 countries, 5 have included PrEP for adolescent girls and young women in their strategic plans to address HIV. Recent data from PEPFAR shows significant declines in new HIV diagnoses among adolescent girls and young women. In the 10 African countries implementing PEPFAR’s DREAMS partnership, the majority of the highest HIV-burden communities or districts achieved greater than a 25 percent–40 percent decline in new HIV diagnoses among young women (https://www.usaid.gov/what-we-do/global-health/hiv-and-aids/technical-areas/dreams). In other areas of the globe such as Latin America and the Caribbean, a combination of biomedical, structural, and behavioral interventions is greatly needed in order to reach target objectives and goals and ultimately increase HIV prevention efforts. I am excited to see the future of PrEP.

Women’s Perspectives

During the women’s perspectives breakout sessions, workshops were broken down into specific focus groups including African American, Latina and Haitian. Amongst the African American women breakout session, some key topics that were addressed included stigma, specifically communication between the medical provider and client such as clear language on how to ask questions during the appointment while also considering time constraints, policy, and the need for funding toward effective behavioral interventions for HIV negative black women in the community.

Sistas Organizing to Survive (SOS) is a grassroots mobilization of black women in the fight against HIV and AIDS. In Florida, one in 68 non-Hispanic black women are known to be living with HIV/AIDS and has been the leading cause of death among black women aged 25-44 years within the state. (http://www.floridahealth.gov/diseases-and-conditions/aids/administration/minority-initiatives.html)

Call to Action

Miami is the #1 city in the United States with new HIV infections. This is a huge public health issue. We have a call to action to advocate for ourselves and others when it comes to ending the epidemic. We have made significant strides, but the work has not yet been done. Sexual health including HIV prevention should be something that we freely discuss with our family, colleagues, peers, physicians, and anyone that we come in contact with that is willing to listen. It is these conversations that we can decrease stigma surrounding HIV. Women across the counties of Broward, Miami-Dade, and Palm Beach have answered the call to action by organizing and advocating for all women. We have accepted the call to action together that we can get Miami to Zero!

“A future where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic circumstance will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”

–Quote from the National HIV/AIDS Strategy Updated to 2020: Strategy Vision

For additional information, please visit http://www.who.int/hiv/topics/prep/en/ http://amp4health.org/ and http://getting2zeromiami.com/

Conference Reflections: Emergency Preparedness & International Health – Different Fields, Same Goals

Last week I was given the opportunity to attend the Preparedness Summit in Atlanta. This conference is the first and longest running national conference that discusses and revolves around the world of public health preparedness (think: natural disasters, medical countermeasures, flu, Zika and Ebola responses, biological threats and much more). There were many different opportunities to learn about preparedness activities including plenaries, small discussions, learning sessions and networking with local, state and federal partners. It was overwhelming, but in a good way!

As an epidemiologist, I have some experience and background in public health preparedness activities, but my main interests and time have always been spent with infectious diseases and global health initiatives. When I worked for the state health department, I actually was on a team that was half epidemiologists and half preparedness staff and we continually supported each other’s activities. Those experiences helped me with preparedness lingo and acronyms used during the conference so that things didn’t go completely over my head. However, I would not consider myself a preparedness expert by any means and soaked up as much as I could from the various sessions I attended.

One of the most exciting activities from the week was visiting the Emergency Operations Center (EOC) at the Centers for Disease Control and Prevention (CDC). This EOC is the center that gets activated in a public health emergency and where experts gather and get ready to respond. The main room of the EOC is spacious, with many computers, television screens and telephones set up and ready to be filled with points of contacts from different divisions and organizations. When there’s not an emergency response going on (like on our tour), it’s actually pretty quiet. However, staff are still on call working to monitor information and sift through potential threats. During a response, I’m sure the place is bustling with people, calls, information sharing and meetings. It was a neat experience to be in the center communication hub where past emergency responses like Hurricane Katrina in 2005 or the 2014 Ebola outbreaks took place.

I did some research after attending the summit and found that the EOC has become an integral part of meeting the goals of the “Global Health Security Agenda (GHSA)”. This agenda is focused on “accelerating progress toward a world safe and secure from infectious disease threats and to promote global health security as an international security priority.” Over 50 countries have joined in partnership with the U.S. to meet this objective and the CDC aims to activate the EOC and respond within 2 hours of any mandated public health emergency. There’s even a fellowship offered by the CDC called the “Public Health Emergency Management Fellowship” that provides an opportunity for public health workers to learn and train over a four-month course then go back to their respective countries and create their own local EOCs. Emergency management experts can also be sent to these countries and help guide and train responders in their own environment if needed.

This post-tour research made me start thinking about the importance of the EOC and preparedness in relation to international health. Public health threats (like pandemic flu, Zika, Ebola) of any degree can happen at any time at the local, state, national, or international level. Bill Gates recently spoke out about the necessity of being prepared for public health threats such as these at the Massachusetts Medical Society 2018. He stressed how unprepared we are for the next epidemic and the world’s need for a “global approach” with “better tools, an early detection system, and a global response system”. Gates’ is most likely alluding to the poor handling of the Ebola outbreaks in the recent past. These are a perfect example of why the field of preparedness is so important to global health. During Ebola, public health response was “too late” and there were too many “deaths that could have been prevented”. There were many disagreements among global health leaders over things like travel bans, how to handle public panic and how to best respond. The aftereffects of the outbreak point to the integral link between a strong preparedness field and international health that was lacking. Gates’ argues that we weren’t prepared to handle prior outbreaks, but we are capable and should spend time and money on planning and preparing for similar epidemics in the future.

Overall, these events – the conference, EOC tour and recent news and outbreaks – have helped hit home that these different public health fields, although working in slightly different capacities, are really aligned and influential on each other. Ultimately, preparedness and global health are working to reach the same goals of keeping our planet safe and healthy and we must first be prepared for any global threat in order to achieve these goals. Today, I feel refreshed in my perspective of the field and inspired and hopeful of future preparedness efforts. I no longer feel that preparedness and international health belong in the different boxes or divisions I’ve created in my mind, but as two parts to the same path.

I challenge other public health workers to also think about the important link between preparedness and global health and advocate for changes that strengthen this partnership. The Preparedness Summit conference is a great starting place and I encourage all fields of public health workers to look into it! I truly believe the more you learn, the more you see how everything is connected and the better you are able to achieve your public health goals … and maybe find some new teammates from other fields to help you along your journey, too.

 

A Highlight from National Public Health Week: North Dakota State University’s “New Perspective on Refugees Roundtable”

Every April, the public health community celebrates National Public Health Week.  National Public Health Week is a time in which we recognize the amazing contributions of public health professionals and highlight the pressing public health issues important to improving our nation’s health. This year’s National Public Health Week theme was Changing our Future Together.

IH Section Councilor Mark Strand organized a roundtable entitled A New Perspective on Refugees in the Community: Changing our Future Together at North Dakota State University where he is a professor. 40 attendees from 12 countries participated in this National Public Health Week event which was held on April 3rd. Attendees learned many things they didn’t know before:

(1) At least one member of the family is working within 6 months of arriving in the U.S.

(2) Over an adult’s first 20 years here, a refugee pays approximately $21,000 more in taxes than they receive in social service benefits.

(3) There is no evidence for increased crime rates among refugees.

(4) There are many positive impacts resettled refugees make on their new communities.

Visit their Facebook post for a look at some of the photos from their event:  https://www.facebook.com/ndsu.chp/posts/10160362153045694

Share your National Public Health Week highlights with us for a chance to be featured on our blog!

Is Zika still a thing? My experiences as a Zika Case Manager in the field (South Florida)

Zika was a hot topic, but now it seems like it is a thing of the past. People always ask me…”Is Zika still is a thing?” And my response is, “Of course! Just because it has declined, certainly does not mean that it isn’t still a public health threat.”

Interesting enough, comments like “Is Zika still a thing” come from physicians and various public health professionals as well as individuals living in regions with active Zika transmission. Those that express more of a concern include individuals that have planned future travel to the state of Florida and are planning to conceive, or a close family member of someone who is currently pregnant.

What is Zika?

Perhaps you never heard of Zika, or still quite aren’t sure what Zika is exactly. Zika can be described as a virus that spreads to people primarily through the bite of an infected Aedes species mosquito. It is closely related to other flaviviruses such as Zika can also be transmitted sexually from a person that has Zika to their partner as well as from a pregnant woman to her developing fetus, which can result in serious birth defects. Want to learn more about Zika? Check out some other IH section blog posts about Zika here.

My role, criteria for testing, testing/funding limitations

I was hired as one of two Zika Case Managers within my local county health department through funding allocated to the state of Florida by the CDC. One of my duties is to coordinate the testing of suspected local, or travel cases, pregnant women, and any infant born to a potentially exposed pregnant woman. The testing criteria for pregnant women include those who traveled to a Zika-active transmission area, had sexual exposure during pregnancy, or 8 weeks prior regardless of the mother’s testing status, as well as those with any abnormal ultrasound results. Testing is also recommended if the mother was not previously tested. Just like other reportable infectious diseases, it takes effective communication between health professionals at all levels to get quality information across regarding Zika. In order to get the job done, we collaborate with infection control practitioners of local hospitals, nurses, physicians, and other public health clinicians to get samples of babies collected at birth for Zika testing while also making sure that a head ultrasound and hearing test are performed on the baby. This is very important because once the baby leaves the hospital it is almost impossible to get samples collected. A majority of the pediatric clinics don’t have the means to ship the specimens to the state laboratories. Some of the general responses we have received from these clinics include not knowing how to properly prepare the specimens for shipping, having the money to do so, and lack of knowledge about billing the patient’s insurance for the procedure. Although the county health department has the access and ability to ship specimens, it would be a liability for us to ship the specimens if another facility collected the samples.

As of March 2017, the department of health has conducted Zika virus testing for more than 13,020 people statewide. At Governor Scott’s direction, all county health departments were mandated to offer a free Zika risk assessment and testing to pregnant women. Unfortunately, due to a decline in cases, and federal funding allocated to state programs winding down, free testing is no longer accessible to the community, and is only provided on a case by case basis. Zika tests can be pretty expensive ranging anywhere from $200 – $400 when conducted at a commercial laboratory and even more in some cases.

State laboratories have just about depleted federal funds received for testing initiatives. If a patient does not meet testing criteria at our department of health, we recommend testing through affiliated commercial laboratories. In addition to the many changes in testing criteria including requiring patients to show proof of insurance, there has been issues with the insurance companies and patients’ have been incorrectly billed over $1000 for their Zika tests when in fact the test was free. This has been a big issue with tests conducted as far back as November and December which we have recently been made aware of. Mosquito control services specifically for Zika efforts provided by our county health department’s Environmental Health program has ended.

Management of Infants with confirmed, or possible Zika Infection

Currently, we have reached the stage where the pregnant women that are case managed have already given birth. We are now tasked with conducting 24 month active follow-ups of all infants exposed to a positive mother via in utero. We conduct follow-up of the infants exposed regardless of whether the infant tested negative, or positive. These infant follow-ups occur at 2, 6, 12, 18, and 24 months. This is because abnormalities can still occur during child development. A majority of our babies being followed are currently between the 12 and 18 month mark.

Out of all the babies we have tested, and are currently following, only one is confirmed to be microcephalic. Looking into the future, at the 18 month follow-up mark, the infants being followed will have to be re-tested in order to confirm if the antibodies are indeed negative or positive. Another complication with testing these babies will be whether the baby has traveled since it has been born. There is a possibility that the baby could have been infected during travel and not in utero. As of July 31st 2018, Zika contracts for our county health department will end and it is unsure who will take on the responsibility for maintaining the case management of these families.

Community Outreach

Best practices we have utilized as a county has been community outreach which we collaborate across the division of communicable diseases. I have been able to work closely with a CDC field assigned Zika Community outreach nurse to assemble and distribute Zika prevention and testing kits with a specific focus on obstetrician-gynecologist and pediatricians. We have been able to identify the gaps in testing and communication among our health department and local hospitals, clinics, and private physician offices. Additional community outreach activities of focus include visiting women, infant, and children (WIC) clinics throughout the county in order to conduct health education on Zika as well as community health fairs primarily within the Haitian population due to Haiti being one of the top countries which we get the most amount of travel related cases. Unfortunately, these outreach efforts will also end at the end of this summer due to the depletion of funds, and our CDC field assigned nurse’s contract ending.

Where we are now

As of right now, Florida still does not have any identified areas with ongoing, active Zika transmission. Florida is a hotspot for vacationers, especially the counties of Miami-Dade and Broward. Since the local transmission of Zika in 2016 in both counties, it seems that very few individuals consider Zika as being a major concern. Very few physicians’ are screening for Zika. Some still aren’t sure what it is exactly, and how it can affect an unborn fetus. Congenital Zika infection is still a global health threat to pregnant women and their infants. Zika is still a fairly new infectious disease, and we are learning as we go, especially the risks after pregnancy. The reality is that Zika is here to stay. Funding for zika prevention and treatment should be a top priority in order to aid in the health and wellbeing of children and families across the United States.