Dear E

When you were tiny, just twelve weeks old, I went back to work. I cried as I gave you a kiss and handed you off to Dad so I could go to my first shift, cried in the car on the drive in to the hospital, cried in the call room as I set up my pump parts, ready to go at a moments' notice, so I could pump even if the ER was packed. I remember the first time I was pumping when a code was called, and I spilled milk and flanges scattered across the floor as I scrambled to grab my badge and stethoscope and rush back down to the ER. At 12 weeks, I was not ready to be away from you. You needed your Momma.

It did get easier, but even as you got older and less dependent on me and my body for love, nutrition and comfort, I couldn't help but have this nagging feeling, this sadness, every time I left. It shifted- from guilt about being away from you when I knew how much we both loved breastfeeding cuddles, to feeling haunted by your cries when I left you in your nanny's arms, even when I found you laughing and smiling with her hours later.

It was a feeling so intense I even turned down a dream job in global health at a reputable hospital, the perfect next step in my career, to be home more with you and baby brother. I was tired of being the Working Mom, constantly missing you, wanting to show up 100% for my job and 100% for you, and feeling like I was failing at both.

Now we're home together as a family of four. I have you and M all to myself (except for Yiayia, who I am happy to share with.) I take you to the playground, to 'cookie dates' at Starbucks, to library class. With M in my arms I tuck you in for naps, help you start an art project or science experiment, make your favorite snacks. The (not so) perfect stay at home Mom.

But now that I've been both Moms, I see things differently. M is 9 weeks. I'm going back to work Friday. Dad will watch you guys while I spend 3 hours at my own Dad's outpatient clinic. You know I am a doctor and that I 'take care of sick babies.' You know I use a stethoscope and bring you back stickers from our nurses at clinic and the busy urgent care one town over. After getting home I trip over myself to change out of my scrubs and hold you. I'm convinced your mommy's home hugs are your best hugs ever. And this broken patriarchal society we live in, I love showing you that I, your mother, can provide for you and for my family.

I'm not sad I turned down the busy hospital job. 15 hour night shifts and a 0.8 FTE are sacrifices I am no longer willing to make for my career, at least not for now. I swapped the high intensity (and high paying) jobs in hospitals for lighter, more flexible work. I swapped the steady paycheck for the ability to say 'no' to work whenever I want to - something that for me feels priceless at this stage in my life. Its a little scary, but I'm thankful I even have this choice. It's a privilege I know many cannot afford.

I used to think that if I succeeded as a doctor I failed somewhere as a Mom, and that if I threw myself into motherhood I was failing myself in my chosen vocation. But it's just not true.

I realize now that it's not that I hated being a working mom. I just needed to do both, on my own terms.

I'm not a stay at home Mom. And I'm not a working mom. I'm just mom.

Love you.

Mommy

Global Health will never be the same (and maybe it's not a bad thing.)

During my time overseas I got tapped to assist with a training session of sorts for the resident physicians at the hospital. A handful of people had flown in from the U.S. to facilitate the sessions, and they ended up staying at the same complex as me and inviting me out to dinner a couple times.

On one night out in particular, one of the visitors casually mentioned over club beers that he was exasperated with his group of trainees. They just weren’t interested in the research topic he wanted them to get involved in. He complained that he wasn’t sure how his study was going to get off the ground in time if they didn’t get on board (and by ‘on time’ he meant before he returned home a few days later.)

I quietly sipped my beer and said nothing. These comments surprised me. I had been around a couple of months and gotten to know several of the resident physicians. Most of those involved in the training session were senior trainees who had their own ideas about what problems concerned them in their patient populations, and what they wanted to study. I also knew a little about this person’s study topic of interest, and from my brief time on the ground knew there were probably a dozen different research projects that, if pursued and funded, could have a much bigger impact on our ability to help our patients.

Fast forward several months and both me and this person are back in the United States, for the foreseeable future or until our government can get itself together and stop being the punch line of pandemic response jokes. I haven’t written about it much (between school and work and life changes I haven’t had much time to sit and write my feelings about the pandemic and global health out) but I have definitely thought about this a lot. How being forced out of so many poorer nations where we are used to being hands on and taking the lead has forced us all to take a step back, to slow down, and really reflect inwardly on what our motives are and how to best move forward if we truly want to be of service.

I am not a perfect global health worker. I have had my share of mistakes and white savior moments. I’d like to think I’ve learned from them, and from my time working with the pediatric team in Liberia, although there will always be room to improve. And I can’t help but think that being forced to stay home, having limited access to all but 14 other nationals in the world, is a good thing for Western global health workers.

For a long time, we’ve been flying in for short visits, trying to use that fleeting time to establish connections, and accomplish whatever teaching or research is on our agenda. But what about our colleagues on the ground? The doctors, nurses, and public health workers that work in these clinics and hospitals every single day, and know the health system like the back of their hand? They see when infants come in time and time again with birth asphyxia, or when their adult patients show up sick and dying from an AIDS-defining illness because of the cultural stigma that keeps them from seeking care for their HIV. They see these problems every day, up close and personal. Are these not the best people to decide where resources go for research, for interventions and system changes? Who are we (myself included) to arrive somewhere for a few short weeks of the year and decide that we know best what the problems are in this hospital, or system, or community? And who are we to decide we know best how to fix it?

I’m not trying to say I’m glad that Americans can’t go anywhere (though it’s definitely the right decision for the rest of the world to shut us out right now.) My time working with the doctors and staff in Liberia was invaluable; I learned so much from my colleagues, and hopefully was able to be of use to the residents and residency program as well. So much can be gained by both parties from long-term, on-the-ground collaborations involving face-to-face clinical time overseas.

But if the pandemic does anything, I hope it forces Western global health workers to take a back seat- let their partners and collaborators in their respective home countries take the wheel and direct the work towards the problems they see as most important. Let’s continue to share resources, but without the many caveats and contingencies we’ve become so hellbent on tacking onto delivery of global health care. Instead of barging in with that brilliant idea already written out into a proposal, work with a partner overseas – help them to draft a proposal of their own idea, to navigate the colonialist world of academia to get their own research ideas off the ground. Maybe this is the kind of work we should have been doing all along.

This is getting long so I’ll cap it here. For some more interesting perspectives on how global health may change in the post-pandemic era from people who are much smarter than I am, check out this link…hope everyone stays safe and well this week!

Weeding through the conspiracies.

Well, hi! If you told me in February I would be back from Liberia, in Boston, working at home while SARS-COV2 wreaks havoc around the globe, I would have given you major side eyes, but here we are. I’ve been working from home about 6 weeks now, mostly doing some data entry with a little bit of analytics thrown in, and a lot of wondering what the future will be like, not just for myself but anyone working in global health and international development.

While I hate that the pandemic pulled me from my field site early, where I was just getting comfortable and learning so much from my patients and colleagues, the switch up of big countries like the U.S. fumbling through the realities of this pandemic while places like Liberia hit the ground running, years of experience with the Ebola epidemic in tow, has been an interesting and refreshing change in the narrative. Not that anyone has the perfect response down (I’m convinced we won’t know what that looks like without some degree of hindsight and reflection,) but it was about time for Westerners to eat some humble pie and realize we have as much to learn from our partners in underserved parts of the world as we do to offer.

There is a lot that is bad about this pandemic (hi, stating the obvious here!) From the little things like not knowing when we’ll be able to hug our loved ones, to the big things like the much worse impact on black communities and the poor, to the plain and simple fact that this virus has killed more a quarter of a million people (see WHO’s latest situation report for more alarming numbers.)

But to me one of the scariest aspects of the Covid-19 pandemic is the misinformation circulating online. Maybe not even the misinformation itself, but the sheer speed at which the conspiracy theories, pseudo-truths and totally false allegations have made their way to social media. Even as patients died gasping for air in overcrowded hospitals in Queens, Facebook experts were calling into question the gravity of the situation, incorrectly crunching mortality rates then spreading the information like wildfire to their social media followers. Information comes out so quickly that it must be extremely difficult as a lay person to know what is and isn’t reliable information. I really do feel for the public on this one, especially those without a background in medicine and research.

Things reached a head late this week with the plandemic video. I was planning to ignore it until it started circulating in a private email chain with family members in the medical field, some of who decided to partially defend the video in the name of censorship and the right to free speech. Americans have always embraced our rights to do and say what we want, when we want, often to a fault (see: vaccinal refusal, or the shooting of a black man going for a jog by armed civilians.) We fight for the right to say and do what we feel is best without government interference (if you’re the right kind of citizen, that is. A conversation for another day.) To live and let live. But what happens when your voice and your circulation of false information endangers the health and wellbeing of others? When your choice not to wear a mask, not to vaccinate, endangers your 65 year old neighbor with diabetes, your newborn niece or nephew, or just the unlucky person you happen to pass by in the grocery store?

I thought about watching the video just to break it down piece by piece. I chose not to because a. it’s 26 minutes and life is short/too precious to waste time on listening to information that sounded incredibly suspect just from the title b. there’s a long and detailed about page that tells me what I need to know and c. several physicians and specialists have already written some great responses. I’ve included them below. Please read them. Some are admittedly more inflammatory than others. If you think or thought at any point that Plandemic was a plausible reality, I ‘ll try my best not to judge you. These are frightening times, and there is a weird comfort in latching on to ‘answers’ like the ones provided in this video, strange and incredulous as they may be.

https://www.npr.org/2020/05/08/852451652/seen-plandemic-we-take-a-close-look-at-the-viral-conspiracy-video-s-claims Great breakdown of the major allegations of the video, put out by NPR. All responses carefully cited.

https://www.facebook.com/jenniferkastenmd/posts/a-response-to-videos-including-plandemic-by-judy-mikovits-phd-on-the-origins-of-/133429318310015/ One of the best, most well-written responses in my opinion. She sticks to facts and avoids inflammatory language that may generate an emotional reaction that stops you from reading. Well cited with reliable sources.

https://respectfulinsolence.com/2020/05/06/judy-mikovits-pandemic/ The first response I saw to the video. Slightly inflammatory. I admit I along with many pediatricians/physicians who have been responding to vaccine hesitancy for several years now do find it strenuous and sometimes tiring to find ourselves in the same arguments over and over again as we work so hard to protect our patients and our families. But this is an excellent piece with citations for every counter-argument. It sticks to the facts.

https://instrumentofmercy.com/2020/05/07/why-your-christian-friends-and-family-members-are-so-easily-fooled-by-conspiracy-theories/?fbclid=IwAR1hkFgPo_zjOAEjmkB_GVGSm_WhWnAJ3ZOx-EXcCmoZWK3f-1HuE9hhGdk Probably the most inflammatory. I am a Christian, and I have also seen a pattern of Christians (not all, but a handful) I am friends with on Facebook, posting conspiracy theory content more frequently than connections from other parts of my life. Skip the intro and dive in at the section titled ‘Why we all love a good conspiracy theory.’ Some really great psychology and logic behind why we as humans are intrigued by these theories and how we can think critically through them.

https://theconversation.com/is-this-study-legit-5-questions-to-ask-when-reading-news-stories-of-medical-research-117836 Lastly, a great read on how to differentiate between good and bad scientific studies. While not directly related to the Plandemic video, a lack of knowledge about science writing and how to critique research articles leaves anyone vulnerable to misinterpreting data, science and facts. I will fully admit that scientific papers can be hard to read and interpret.

I hope these responses to the Plandemic video are helpful to you. No offense meant in any way. While I am happy to answer questions and have healthy discussions, I am not interested in debating this video so please don’t comment or message me with comebacks as to why I’m wrong or the video is correct. I’m not changing my view on this one and if you aren’t open to thinking differently about these issues this isn’t the place for you.

Stay safe everyone,

Untitled (just call it insomnia.)

During my first year of residency, I cared for a little girl named Z*. She had been on the oncology ward for months, fighting an aggressive blood cancer that hadn’t remitted despite several courses of chemotherapy, each regiment more aggressive than the last. She was on my patient panel for most of my month of heme/onc, and during the entire time she was miserable and in incredible amounts of pain. The only things that seemed to soothe her were sips of water, leg rubs from her mother, and watching Frozen on repeat. By the time I was caring for Z, her mom had a newborn and couldn’t spend nights in the room alongside her daughter anymore. I remember spending a good chunk of my week of night float sitting quietly next to her, watching Elsa sing ‘Let it Go’ over and over and over again, while she cried and asked where her mother was.

Z passed away while I was home one night in between shifts. It was pretty fast - within a few hours of becoming unstable and being transferred to the ICU, she was gone. It was the first time I was up close to a child passing away. I had seen death before, both in medical school and in residency. But I hadn’t seen suffering- not like this, anyway- in such a young and vulnerable child. It was completely heartbreaking. Sometimes you reach a point in caring for a patient when you feel helpless- like your interventions aren’t helping, and maybe by prolonging suffering they are causing more harm to the patient than good. I felt like we had failed her- not because she died, but because she was in terrible pain during much of the end of her life, and maybe instead of fighting her cancer so aggressively, we could have done more to make the end of her life peaceful and less painful.

I didn’t know it at the time, but I was experiencing my first real bout of moral distress. It is broadly defined as a scenario when a healthcare professional feels that they know the morally correct action to take to care for the patient, but are restricted in some way from taking that action (more on the topic of moral distress can be found here, if you’re interested.)

Now all these years later, as I adjusted to working as a pediatrician in a very busy, very high-acuity unit in a low resource setting, I began thinking about this case again. Nearly every day, choices have to be made that bring back those unnerving feelings of discomfort. They don’t all revolve around death, but all revolve around struggling with knowing the right course of action, and not being able to execute it properly. The child we send home who may need a few more days of antibiotics, because there’s no more space in the unit and we need to make room for the next sick child; the infant who goes days without getting the correct antibiotic as the family scrounges together the few resources they have to pay for it; the patient we can’t put on CPAP or oxygen because the only supply available is being shared among several other patients at once. Moreover, when our ability to test and find a cause for a patient’s illness, decision making can become a lot harder (this is related to another type of moral distress related to uncertainty.)

These are challenges I was peripherally aware of during my time in U.S.; they came up rarely, as most of my patients were healthy and resource allocation is not a challenge you have to deal with often. My colleagues here have faced this every day for years. They have incredible knowledge, perseverance and compassion, but underneath the surface is a palpable frustration- a feeling of helplessness, of uncertainty of what exactly needs to be done to tackle some of the systemic challenges we face.

I started writing this in the middle of the night, during a bout of insomnia, but initially struggled to find a satisfactory conclusion, some enlightened wisdom to wrap this thing up in a neat little bow and end on a positive note. A few weeks is not enough time to unpack things, to pick apart the machinery to find the pieces that are broken, and its certainly not enough time to know how to fix them. People who have lived and worked in this environment this every day don’t have all the answers, so how on earth can a Western pediatrician with a few weeks of working here have them in such a short time? I suppose the best I can do is use this feeling of discomfort to keep trying, every day, piece by piece, to understand the fabric, the strengths and the failures of the system here, and support in whatever small ways I can. In the meantime, I suppose I’ll have to get used to this strange discomfort- after all, everyone else here has been dealing with it for years.

*name has been changed.

One day in a Liberian Pediatric ER

I can't believe a month has gone by since I arrived in Monrovia! A month feels like a long time and no time at all with the pace at which things happen here. On the one hand, things move slowly...getting anything done (even something as simple as a blood pressure, and even in an emergency situation) can feel like it takes ages. On the other hand, time flies by as the days that are packed with dozens of sick patients needing various evaluations and interventions.

I thought a month was enough time to share a bit about what my day looks like here. Because there is a residency program, a lot of aspects of the day are familiar, with a Liberian twist :) No days are exactly alike but they tend to have a general pattern, something that goes like this:

6:10 am: alarm goes off. Depending on how late I stayed up worrying about this or that sick patient, I either hop out of bed to do a quick home workout or scroll through my phone a bit. I drink a ton of water as there's no clean water to refill my nalgene bottle with at work and take my anti-malarial pill. I usually listen to a podcast or audiobook while getting dressed ready to go. Liberian doctors tend to dress pretty formally (and have great style) so unless you're on call no one wears scrubs- they will typically dress in business attire with a lot of beautifully patterned custom-made dresses and suits sewn from lappa fabric (more on that another day.) I usually wear business attire and a white coat with a small notebook, pen and the WHO blue book (basically a global health pediatric bible) in the pockets.

7:00 am: the sun has started rising just enough that its safe to walk to work (as someone who is obviously Western you can't really blend in here, and petty crimes aren't uncommon.) I usually bring my breakfast to work- a banana, coffee and peanut butter smoothie that I may have become slightly addicted to. The hospital is 15 minutes away and if the weather is nice I get to catch a beautiful sunrise through the Sahara dust that blankets the atmosphere during the dry season.

Beautiful mural at the hospital's main entrance. It depicts the history of medicine in Liberia, including the traditional healers all the way up to the present day. 

7:15 am: I arrive in the pediatric emergency room to pre-round. The room is shaped like a T- the base of the T has a a row of chairs on one side where patients who have been triaged wait to be seen, and a large desk and chairs on the the other side where the docs can sit and review charts, interview patients and document. Unless there is an active resuscitation going on (which isn't that uncommon,) I sit down here and review the charts.

The top horizontal bar of the T contains 8 patient beds (there's also two doors to the left- one leading to the outpatient department, one to another room for patients who will have shorter admissions.) These are the sickest and/or newest patients. After reviewing the vitals, notes, diagnosis and medications served, my goal is to examine all of these kiddos before 8 am. Because of the aforementioned codes/high acuity (new sick patients arrive all the time, or I may get caught up addressing a patient who is getting worse right in front of me), this doesn't happen as much as I'd like. You just kind of have to take things as they come here.

8:00 am: morning meeting occurs on the wards in the main hospital, meaning I am usually dashing upstairs at 7:55 am to grab my white coat and make it in time (some things never change; I will forever be afraid of lateness, even when it isn't uncommon here.) Similar to the U.S. system, the overnight team presents all admissions from the last 24 hours, as well as any deaths. The consultants (attendings) and specialists (board eligible pediatricians in the process of becoming attendings) will comment and highlight teaching points on various cases. The West African medical teaching and lecture style is pretty formal compared to American training, but I try to weigh in occasionally if I feel I have a useful or unique perspective to add. Residents and attendings can also share announcements, concerns and issues at the end of morning meeting so they can be discussed in an open forum where everyone can have their say.

9:30 am (ish): this is where the day becomes more fluid. After morning meeting I head back to the peds ER for rounds. Depending on the specialists, rounds can either involve significant teaching, be rapid fire/brief, or not happen at all if the ER is very chaotic with a large volume of patients to see. We usually have several medical students, an intern and 1-2 residents around to present each patient, discuss the current medications and plan, and decide what the next steps in care are.

Something that's been a fascinating adjustment for me is patient ownership. In the U.S., as a resident I'd arrive on the wards each morning with a neat list of 5-10 patients I was primarily responsible for that day. Here, every patient is under the care of all of us as a team; the resident presenting the patient is arbitrarily chosen and the third year, specialist and consultant all agree on the plan together (though the most senior person has the final say.) Its been a fascinating deviation from what I am used to that is a better fit for the Liberian culture and practice style.

We see a lot of very sick patients; birth asphyxia (when the baby is deprived of oxygen and comes out critically ill with neurologic damage,) sepsis and other infections, and severe malnutrition are incredibly common and come with very high mortality rate.

One factor we consider in decision-making that I didn't expect was the cost to families; apart from a limited selection of medicines, everything we choose to do costs money. From a CBC to an x-ray, to selection of the correct antibiotic, parents have to scrounge up what little money they have to buy sometimes life-saving treatments for their kids. For a parent who makes only a dollar a day, even spending five dollars on a lab test or medication can be close to impossible.

Noon- 2 pm (ish): after rounds I tend to stick around for a bit to see how I can help without impeding work flow. This could mean I am writing in the chart, following up on a blood pressure or discussing a complex case a bit further with the residents and specialists. Eventually I make my way upstairs to work on research, helping the residents gain uptodate access, and looking up papers and articles on various interesting cases we've had to share with the team.

2 pm- 5 pm (ish): Depending on the day, there's loads of things going on during this time. Like any residency program, various lectures are given, either by the residents or by a local or visiting consultant or specialist. There are also various official exams at any given time of year; currently the first years are preparing for their exams (something between a Step 1 and Step 2-type of test) and we meeting regularly to review topics and go over questions. I also spend time with our research nurse entering data, tracking down missing information and troubleshooting whatever issues may be arising in the ongoing research work on a given week.

While the clinical work is a great learning experience for me, I find my work in the afternoon to be more rewarding; because of resource limitations there's not a whole lot I can do to improve outcomes on the level of individual patients. It can be incredibly emotionally draining to see your third newborn in 24 hours die from the same preventable illness (true story. More on that later.) But with collaborative research, and with actionable, big-picture policy changes, slowly over over time you can start to enact meaningful changes, and hopefully over time see improved outcomes.

5 pm-6 pm (ish): I check in with the peds ER 1 last time before heading home. If things are quiet, this could just be hanging out with the specialist, or reviewing patients of concern (watchers) with the overnight resident team to come up with contingency plans. Its not unusual for an actively crashing patient to be rushed in though, requiring resuscitation of some kind. These cases are the hardest because if I don't leave before dark it isn't safe to walk home, and because of recent gas shortages its not always easy to find a cab to drive you. So much of this job causes scenarios like this, of moral discomfort. I can't say that leaving feels like the right thing to do, but I can't help anyone if something bad happens to me. There's way more to unpack there than I feel up to sharing at the moment, but it is definitely an uncomfortable conundrum I encounter pretty regularly, so it would feel odd not to at least acknowledge it.

My favorite fruit stand...its bananas how good the bananas here are (pun intended)

6 pm: If I don't stop at the supermarket or fruit stand by the hospital to grab more bananas, I arrive home, usually covered in sweat. I tend to immediately throw on my swimsuit and jump in the pool to cool off if I have time. Taking a couple minutes to swim some easy laps and unpack what I've seen/heard/felt throughout the day helps me to transition from the "everything is on fire and everyone is sick" mode into a more relaxed and reflective state. I tend to cook something easy and quick, maybe watch 20 minutes of a show while having dinner, then read on a few topics I jotted down throughout the day or get some research work done, depending on what's on my to-do list.

9 -9:30 pm: wind-down time before bed. One thing I really appreciate here is a consistent schedule; not working evening and overnight shifts like I do in the U.S. is one of the nicer luxuries of my time over here. The overnight team can call me any time but usually don't unless there's something they feel I can specifically help them with. I usually read a novel, listen to a podcast, watch something or whatsapp call family before going to bed around 10 pm.

And that's a typical day as a clinical pediatric fellow in an urban Liberian referral hospital! In the future I may share more of the specific types of cases we see, or how the health system works, and hopefully introduce some of the incredible doctors I have been working with, but for now I just wanted to share what happens on a day-to-day basis. Hope its interesting to someone :) Feel free to share any particular questions or thoughts in the comments. PS- You can also follow along on instagram if to see more of the day to day things, if you are curious.

Global Health Careers: Part II

Ok, so here’s part 2 for global health career paths… I am a physician so this is pretty physician-geared, but I want to re-emphasize that there are tons of areas of work in global health, many of which don’t require any sort of clinical degree. I just wanted to share some of the resources I’ve accrued in case anyone else is interested in this kind of work. These ideas are by no means an exhaustive list. I sorted these out chronologically/by career stage so it should feel like a sort of pathway into global health from start to finish, but if I’ve learned anything in the last couple of years its that there are probably dozens of ways you could go about doing this and there’s no ‘right’ way to pursue a career in global health. Hopefully its helpful to someone interested in getting involved in this field :)

Undergraduate/pre-med. With some exceptions, I would not rush into field work at this stage. Unless you have something concrete to offer such as EMS skills or language proficiency, I really would spend this time learning, reading, and absorbing everything you can from the field of global health. Work experience overseas is great, but be selective about the programs you choose to become involved with. You never want to be in a position where your presence is causing more harm than good. For me working through a Fulbright grant offered a great opportunity to work overseas doing research without becoming involved in direct medical care. It was easily one of the coolest things I’ve ever done. For more information on how to apply for a Fulbright Grant, see their website here. 

In the meantime there are plenty of great resources you can explore to continue learning about the field- you can follow mailing lists such as NPR’s Goats and Soda, Johns Hopkins’ Global Health NOW and the Center for Global Development. There are also many great books- too many to list, but Mountains Beyond Mountains and The Spirit Catches You and You Fall Down are two that I was recommended again and again.

Right after undergrad is also not a bad time to pursue an MPH, especially if you’re still not sure if clinical medicine is for you, or you’re not sure your application for medical school is strong enough yet. If this isn’t you, I’d strongly consider waiting until during or after medical school. The reason for this is twofold: one, if you hold off on getting your MPH until residency or fellowship, there’s a good chance someone will pay for it for you- yay! Secondly, a master’s degree in public health is the kind of graduate training where it kind of does matter where you go. While you don’t have to go to a top 10 program, you should definitely aim to go somewhere with a robust global health curriculum and reputation, as networking is one of the key reasons to get an MPH. Here’s a list of some of the top master’s programs when it comes to global health. 

Medical School. Ok so first off, just learn how to survive and thrive in the insanely rigorous environment that is medical school. If you plan to practice clinical medicine, the best thing you can do to prepare yourself for a job in global health is to learn great clinical medicine. Once you feel you’ve found your footing in medical school, you can start to seek out opportunities and experiences in global health. This may take the form of a rotation overseas or online, an interest group, a spring break trip or lecture series. Whatever you do, I still think you should prioritize quality over quantity- make sure if you are going to work overseas your have adequate supervision, and your presence is not causing more harm than good. This may mean an ‘away’ rotation with a medical school that has a well-established, positive relationship with a hospital overseas rather than an experience with your own school.

Medical School is also a great time to consider an MPH; some people take time to do it before clinical medicine rotations begin, or before they apply for residencies. You’re already going into a ton of debt so it will be a balance of finding the best program for global health you can get accepted into and the program that won’t cost you an arm and a leg (this is key! It’s a lot harder to work in this field if you accrue a ton of loans.) On that note, while virtually everyone takes on loans for medical school, if you truly want to pursue a career in global health, you want to know all your options, and consider things like scholarships and the public service loan forgiveness programs.

Residency. Again, step 1 is focusing on becoming a strong clinician. But before you submit your rank order list, if you are considering a career in global health, I would strongly, strongly recommend ranking programs with global health tracks. These tracks vary widely, from a few courses with a short project assignment to an entire extra year sent at a site overseas. In pediatrics the programs doing the most in global health are generally Boston Children’s, CHOP, UCSF and Baylor School of Medicine, but there are plenty of small and mid-sized programs with great opportunities as well. A quick google search will give you pages and pages of info, and the ABP guide (linked here) is also a great resource and guide for trainees interested in global health tracks and pathways.

If you aren’t at a program with a strong global health track or presence, don’t worry. There are definitely still options to stay involved in global health. Baylor’s International Pediatric AIDS Initiative offers 4-6 week rotations to outside residents. I also did nearly all my mandatory presentations on global health topics, from journal clubs on hand-held echo use in diagnosis rheumatic heart disease to resident as teacher talks on HIV/TB. Staying involved in global health societies, such as the Consortium of Universities in Global Health, and the AAP’s SOICH (if you are in pediatrics) other ways to continue to network as you complete your training.

Everything else. Once you’re an attending, the world really is your oyster. If you are truly passionate about a subspecialty field, now is a great time to become involved in global health as a fellow, as there’s huge need for specialty care in low and middle-income countries worldwide. ID, critical care, neonatology and emergency medicine tend to be subspecialties with a decent amount of overlap with global health, but it does vary A LOT from program to program.

I was somewhat undecided about subspecialties, and wanted more on the ground clinical experience, so I went for a global health fellowship. Only a handful of pediatric programs offer an entire fellowship for global health (At the time that I was researching options last year it was UCSF’s HEAL program, Utah, CHOP and Boston Children’s Hospital.) Some are more research driven and require NIH K-grant funding, while others (like mine) are funded through the fellows working as gen peds clinicians in community hospitals for half the year to fund the other half of your time being spent working abroad. A big driver for me was that I am getting part of my MPH funded (yep! Another reason waiting to get your MPH isn’t always a bad idea) but I also feel very, very lucky to be able to work with and learn from the network of people here who are doing amazing things in global health.

I will also say many people just get out there and practice global health. This may be through a U.S.-based program (BIPAI hires general pediatricians for their HIV clinics, and Seed Global Health hires physicians to teach Helping Babies Breathe Curricula in resource-poor settings) or through an international NGO (MSF is very competitive and offers only longer stints unless you work in certain specialties, but there are many smaller organizations looking for physicians to assist with various projects.)

One extra option I’ll throw out there- the CDC has a field epidemiologist training program that basically trains both physicians and non-physicians to address epidemics in the field and is another great way to get on the ground experience and training. The UK and EU also have a similar track.

Hope this has been a helpful guide to anyone who is interested :) Feel free to message me or comment if there's anything you're particularly curious about. 

  

Global Health Careers: Part I

Crete, 2015

I was interested in global health and international work pretty much from the outside of my interest in medicine as a career. In the dozen or so years since then, the field has evolved tremendously, shifting towards more long-term and sustainable solutions and working in partnership with the local medical communities, rather than the short-term mission-style model.

Back when I started on this path I had no idea what a career like this entails; in many regards its still a learning curve and I’m figuring a lot of it out as I go. My first global health experiences in college were not great, though I didn’t realize it at the time. I joined a group of students to triage patients and distribute medications and vitamins during a couple of week-long missions in Central and South America. At best we were helping with workflow at a quarterly pop-up clinic, but at worst we were screening for diseases we didn’t have the medicines or resources to treat, without appropriate medical supervision. While we probably didn’t do any harm (something that can definitely happen in situations like this- see this new story for an extreme example), we certainly weren’t doing anyone any good.

The experiences left a bad enough taste in my mouth that I decided to stop working internationally and for the time being focus on learning good clinical medicine. I put the idea of international relief on the back burner until I had to skills to truly contribute something. But when the time came for that, I was a little lost as to how to go about pursuing a job in the field of global health. With a ton of guidance from mentors and acquaintances (and even more deep dives on the internet and google searches,) I found a few different career paths, job opportunities and fellowships that helped me formulate a much clearer plan for how to use my medical degree and pediatrics skills to serve others.

So for starters, here are a couple of things I learned during the last few years that I think are really important. I will get more into the nuts and bolts of global health careers in the next post.

With the medical director for one of BIPAI's many satellite clinics, Lesotho, 2017

1.     Approach work with humility. This is really rule number 1, 2 and 3 for doing good work in global health. While there are definitely things that can be brought to the table as a U.S.-trained physician, I guarantee my colleagues in Liberia are much more skilled than I am at dealing with malaria, malnutrition, other diseases we don’t see very often in our training. The history of global health is not so neat and pretty as you may think; its riddled with outdated, colonialist and often exploitative motives and strategies that are better off left behind as we move forward. I will be learning as much from the physicians and nurses in Liberia as they’ll learn from me. The absolute last thing many low and middle income countries need is another foreigner barging in, enforcing ‘better’ Western ideals and leaving a mess behind, or worse, gaining credit and fame for work and research done in these countries with no recognition for the health workers on the ground who were integral to getting this work done. As soon as you realize this work is not about you, you’ll already be in a better place to make a difference.

2.     Find a good mentor. Emphasis on good. I wish this had happened to me sooner. As a woman in medicine, pursuing a field that is somewhat atypical, I spent quite a few years feeling lost and rudderless, trying to figure out where I fit in to the big, messy picture that is global health work. I spent way too much time trying to fit myself into expectations of what a doctor’s career should be, and then feeling bad about myself for not really fitting that mold or being happy with who I was becoming as a physician. That all changed once I found a mentor who actually listened to me, tried to understand what I wanted to do, and then did everything in their power to get me to where I am today. I’ll never, ever forget that feeling of realizing this person was there to help me grow, advise me and achieve my own goals, rather than push me into a place or position I didn’t quite fit in. This is so, so crucial, really in any field, but especially for women in medicine and anyone interested in global health. (Sidebar: it may feel like you need to find someone who has a lot of global health experience, but I’d argue you should  pick a mentor based on their enthusiasm and investment in you; someone who is as passionate about your career as you are will be a much better mentor than a more experienced but indifferent person who happens to work in the field.)

3.     Be prepared for burn out. We all know medicine pushes humans to the absolute limits; the long hours, frustration of trying to navigate a broken system, and constant interface with human stress and suffering take a toll on everyone (and if someone says it doesn’t, they’re lying.) These challenges multiply when you enter a system with fewer resources and higher mortality than we are accustomed to as American health care specialists. You can’t help anyone if you develop compassion fatigue and burn out. Know what keeps you going and have an ‘emergency’ plan for those days that are really, really hard. For me its spending time outdoors and skype dates with friends and loved ones; for a colleague its Nutella, face masks and venting sessions with friends in the field. Set time limits to your work days, realize that you as a single person cannot fix every single problem you encounter, and give yourself the grace to accept it.

That’s it for now, I’ll try to write up some of the many, many career options I’ve found in global health in the next couple of days :)

Off to Liberia (next week.)

Source: https://www.dreamstime.com/royalty-free-stock-photography-sierra-leone-liberia-image4954487 

Since I have a couple days of downtime thanks to some surprise visa issues I figured now was a good time to share a little of what I've learned about Liberia in the months leading up to this trip. Apart from the usual resources such as the CIA world factbook, good old Wikipedia, and google news alerts, I learned a TON from Helene Cooper's Memoir The House at Sugar Beach (linked here). It was riveting and beautifully written, definitely a must-read if you are interested in this part of the world. I am currently reading her book Madame President: The Extraordinary Journey of Ellen Johnson Sirleaf, which you can find here.  I've also been following this blogger to get some insight into the culture and what daily life is like in Monrovia and elsewhere in the country.

I also feel its important to say you could write an entire textbook on this nation's history and I am in no way an expert on this subject; I am just sharing the major highlights and parts of Liberia's history, culture and traditions which I've found really interesting.

While the country was founded by American freed slaves, prior to their arrival over a dozen distinct tribes with their own kings, traditions and customs lived across the region for centuries. The American Colonization Society funded the emigration of a group of former slaves to the West coast of Africa between 1820 and 1843. Although it seemed like a beneficent idea to many, most African slaves at that time had lived in the United States for generations and were not prepared to re-settle on the humid, tropical West coast of Africa. Many became sick and died; just under half survived to 1843, while the ACS continued to fund the journey until the foundation because bankrupt and essentially abandoned the existing settlements to stay afloat. The Americo-Liberians, who came to be known as the Congo, declared their independence in 1847.

From that point until 1980 the Congo minority ruled over the indigenous groups of Liberia in a government model very similar to the United States; being Congo generally meant you were wealthier than the 'country people' and had far more agency than indigenous people of Liberia (does this sound familiar?) Ongoing corruption and skyrocketing prices of basic food and supplies in Liberia led to several often-violent political upheavals between 1980 and 2003. All told 250,000 lives were lost, and many more fled the country. By 2003 much of Liberia's infrastructure was destroyed.

From 2003 onward Liberia has experienced much more stability, but still faces challenges from corruption, exploitation from foreign companies such as Firestone (here's a well-done piece by the Washington Post on the topic and another multi-part longform article from Propublica) and the 2014-2016 Ebola epidemic.

By Sahmeditor - Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=3575700

In spite of these hurdles, Liberia is a beautiful, culturally diverse and naturally rich place with great potential for growth. While mortality rates remain very high due to diseases such as malaria, tuberculosis and diarrheal illness, a training program exists at the main hospital in Monrovia, where I'll be working, to produce more Liberian-born pediatricians to tackle issues in infant and child mortality such as neonatal disease, early childhood pneumonia and malaria, and malnutrition. Some other things you may not know about Liberia:

• Most Liberians speak English- Liberian English, which is actually a collection of creolized dialects of English. Another 30 or so languages are also spoken in pockets throughout the country by various ethnic groups
• Liberia's people consist of 16 ethnic groups, in addition to the Americo-Liberians (Congo) and several expat groups. 95% of the population is made up pf these indigenous peoples, including Kpelle, Bassa, Grebo, and many others. 
• Due to the influence of the Congo people who came to Liberia from the U.S. in the 19th century, much of Liberia has influences of antebellum south, from the building styles to the religious culture. 
• Liberia has some great literature- next on my reading list is Murder in the Cassava Patch by Bai T. Moore (see the wiki page here)
• Something else I'm looking forward to trying is the FOOD. Rice is a staple as are cassava, fish, citrus, plantains, okra, coconut and sweet potatoes. Stews are often flavored with habanero and scotch bonnet chillies (insert flame emoji here) and eaten with fufu, a combination of plantain and cassava flour mixed with water. Check out Anthony Bourdain's No Reservations on Liberia for some mouth-watering visuals (linked here)
• Liberia had a thriving tourist industry prior to the war. With gorgeous beaches to the West and tropical mountainous regions to the East, its natural beauty landed it on Lonely Planet's list of top 10 places to visit in 2020. There's even a growing surfing community at Robertsport. So if anyone's looking to escape the snow this spring, you know where to find me. (Bonus: the USD is widely accepted!) 

That's all for now. I 

How I Feel About Vaccines

Photo by Caleb Woods via unsplash.com

When measles cases in Brooklyn and Rockland county shot  past the hundreds last spring,¹ I began to realize the gravity of the situation at hand. In the hospital where I was working, we had already admitted several children with severe measles infections and a young boy with a superinfection of his chickenpox rash that required intravenous antibiotics. In our pediatric ICU, a strong, healthy high school track star was intubated and fighting for her life after contracting pneumonia following a severe bout of the flu. These children could have avoided significant pain and suffering had they been vaccinated. 

I wish vaccine-hesitant parents could see what I see. Measles, flu, even varicella- these diseases can cause tremendous suffering, and even death. In 2019 more people in the Democratic Republic of Congo died of measles than of Ebola.² In the U.S. the 2017-2018 flu season left an estimated 80,000 people dead.³ 186 of those were children.

When I reassure vaccine-hesitant parents that there is incredibly strong evidence that vaccines are safe and effective, and that the study suggesting an association between vaccines and autism has long since been debunked,⁵ it doesn’t seem to work. It’s a matter of choice, they tell me. Of their individual right as a parent. But the problem is that this is a choice that affects the health and safety of other people, too.

Viewing vaccine choice as an individual right and issue does not take into consideration the dual purpose of vaccines. Yes, vaccines will prevent an individual from becoming ill. But they also have another crucial effect: herd immunity.⁶ When at least 90%-95% of a population is vaccinated (the number varies slightly by vaccine,) the illness becomes less common and everyone is protected,⁷ including those who cannot be vaccinated because of their age or health. They can go to school, to parks, or to other public places with little worry of becoming ill, because the herd of vaccinated neighbors, schoolmates and cohabitants protect them. What should these children do now that vaccination rates in some communities hover as low as 50%? Measles is so aggressively contagious that we shut down our entire urgent care clinic for cleaning when a patient was diagnosed. For children who are to sick or too young to get the MMR vaccine, even walking into your doctor’s office during an outbreak becomes unsafe.  

Photo by Hyttalo Souza via unsplash.com 

To be fair, the medical community shoulders some responsibility for vaccine refusal and hesitancy in the United States. In the age of endless information, perhaps it’s been too easy for us to be dismissive of parental concerns and hesitation, without delving deeper into where these concerns are coming from. Some communities have genuine reason to view the medical community with doubt and suspicion, given the Tuskegee syphilis experiment,⁸ or the coerced sterilization of some minority women.⁹ Perhaps we have been too quick to tell parents to stop googling, when we should have been having open conversations about why families seek out alternative, questionable sources for information in the first place.

Shortly after the outbreak was declared I was back on the wards. The child with chickenpox had lost his IV, and I was asked to help replace it using an ultrasound machine, since his severe rash was making the task difficult. Even before I entered the room, I could hear him crying. He had been miserable for days with significant itching and pain. As I prepared to place the intravenous line in what was probably a third or fourth attempt that day, a strange thought popped into my head. I wondered if this little boy was given the option of getting vaccinated or being subjected to this, what would he have chosen? 

Note: certain details in this story have been changed to maintain patient privacy. All of the cases discussed are real. All words, thoughts and opinions are my own. 

References

1.     Goldschmidt, D. (2019, May 13). More than 800 cases of measles in US, with NY outbreak continuing to lead. CNN. Retrieved from https://www.cnn.com/2019/05/13/health/measles-update-cdc-800-cases/index.html

2.    Rossman, J., & Badham, M. (2019, September 18). Over 3,000 people have been killed by a deadly virus in DR Congo this year —and it’s not Ebola. Quartz Africa. Retrieved from https://qz.com/africa/1711485/measles-is-killing-more-people-in-dr-congo-than-ebola/

3.  Center for Disease Control. (2018). Estimated Influenza Illnesses, Medical visits, Hospitalizations, and Deaths in the United States — 2017–2018 influenza season. Estimated Influenza Illnesses, Medical visits, Hospitalizations, and Deaths in the United States — 2017–2018 influenza season. Retrieved from https://www.cdc.gov/flu/about/burden/2017-2018.htm

4.  Vaccine Safety: The Facts. (2018, October 10). Retrieved October 23, 2019, from https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccine-Safety-The-Facts.aspx.

5.   Eggertson, L. (2010). Lancet retracts 12-year-old article linking autism to MMR vaccines. Canadian Medical Association Journal, 182(4), E199–E200. doi: 10.1503/cmaj.109-3179

6.     Boyd, R. (2016, April 18). It Takes a Herd. Retrieved October 23, 2019, from https://www.aap.org/en-us/aap-voices/Pages/It-Takes-a-Herd.aspx.

7.  Funk, S. (2017). Critical immunity thresholds for measles elimination. Critical immunity thresholds for measles elimination. London School of Hygiene and Tropical Medicine. Retrieved from https://www.who.int/immunization/sage/meetings/2017/october/2._target_immunity_levels_FUNK.pdf

8.  Brown, D. N. (2017, May 16). ‘You’ve got bad blood’: The horror of the Tuskegee syphilis experiment. The Washington Post.

9.    Ko, L. (2016, January 29). Unwanted Sterilization and Eugenics Programs in the United States. Retrieved October 23, 2019, from http://www.pbs.org/independentlens/blog/unwanted-sterilization-and-eugenics-programs-in-the-united-states/

Maintaining Sanity on Night Float.

My sister recently started her sub-internship on night float (side bar: my sister is in her last year of medical school?! Cue the quarter life crisis) and it brought me back to those good old days when I was a wee intern….

And didn’t sleep, froze my butt off every night, and jumped out of my skin with every page, even the ones that were just asking for a Tylenol order. 4 years later, I have a weird appreciation for working in hospitals at night- the quiet hallways, being able to chat with patients and their families uninterrupted, and getting so tired you start laughing at the most nonsensical things with your senior resident. I figured I’d write this out for my sister (if she reads this blog, she might be too cool for this kind of thing. LOL) and any other new interns or almost-interns about to dive into their first experience working nights at hospitals.

Get comfy. Night float shifts are often long, lasting anywhere from 10 to 14 hours. Many nights you’ll be on your feet a lot, and won’t be spending a ton of time sitting or resting, so good shoes are key. Many healthcare workers swear by Danskos; a well-fitting pair will last you for ages ( one nurse I work with has had hers for 7 years,) but make sure to try them on before you purchase, as each pair is handmade and therefore will fit slightly differently. I personally have loved wearing my Allbirds and have also used my running shoes in the past; both worked fine for me.

Another thing people don’t realize off the bat is that hospitals are cold, and they get even colder at night. I would walk into work wearing fleece leggings pretty much from August through mid-June. A fleece or zip-up jacket plus cozy socks and you have a semi-tolerable work environment. Some of my colleagues even had a hospital blanket stowed in their lockers.

Have a sleep strategy. I have never been a good sleeper. I am one of those people whose brain likes to play the game of ‘lets dive into your most cringe-worthy memory or deepest regret!’ as soon as my eyes shut, and breaking routine can really exacerbate my insomnia. I generally had two approaches to sleeping on call- I would prioritize trying to get REM sleep in at least once; at my hospital I had to follow up on midnight and 4 am vital signs, which meant I could sleep for 4 hours in between if my brain would settle down or I was tired enough. If sleep wasn’t coming easily, though (like, say, if I was having the recurring nightmare of the code pager going off and my legs turning to jelly. That was a fun one.) I would hammer out some work- either easy readings, life stuff that I’ve been procrastinating on, or mindlessly running through a few board prep questions. About half of the time these activities were boring enough that I’d eventually nod off.  

There were definitely nights I wasn’t going to be able to sleep; you just have to accept that you’re being paid to work no matter what, and that being paid to sleep is a kind of bonus perk that happens once in a while, but isn’t guaranteed. This mentality helped keep me from getting too stressed out if my grand plans didn’t work out.

Another semi-related tip for interns: do your own night rounds. You certainly don’t have to see every patient, but walk through each unit shortly after nursing sign out to check in, see what’s going on, provide updates and change or correct orders as needed. I would even bring a computer around with me to change orders in real time. This does two things: first, it shows the nurses that you are attentive and care about their contribution to the patient’s care plan. Getting friendly, recognizing names and faces and even engaging in small talk really does go a long way. Second, it reduces the number of pages you will get at 2 am to change that Tylenol from round the clock to as needed, or other non-urgent matters. 😊

Time your caffeine boluses. I tended to be sensitive to caffeine. It made me jittery and jumpy, and would occasionally exacerbate an essential tremor that came out of nowhere in residency. I would usually drink a half cup of coffee before work, then, depending on how the night was going, either plan to lie down and sleep and have another coffee or tea before signout, or on PICU nights when I knew I’d be up, time an 11 pm- midnight coffee to keep me going until signout.

Maximize your home rest. I think of this as two parts- creating a cozy environment to sleep in regardless of time of day, and balancing the need for sleep with the need to maintain a normal circadian rhythm. For me this usually meant blackout curtains and ear plugs (you’d be surprised how noisy it can get during daytime hours at home) plus a 3-4 hour nap, then getting up to do errands or enjoy some sunshine, have dinner, and go to bed early so I was rested enough for the next day. I always found days that I slept much longer than 4 hours led to trouble sleeping later in the evening that could worsen my insomnia for days.

Others I’ve worked with have used working out right after call to ensure they get really good sleep, taking melatonin, or just pushing through the day and going to bed early in the evening. The bottom line is you have to figure out what works for you, but in general if you go into REM sleep for too long, your brain is going to be confused and think you need to be awake every night.

New Year's 2016, celebrating with sparkling grape juice in the pediatric ICU

Have fun. No, really. While there are definitely plenty of rough nights to be had in residency, there's also some true camaraderie to be had on night shifts. Some of my deepest conversations with colleagues and coworkers occurred on night float. Some of us had ‘family dinners’ where all 9 people on the floor teams at night would order Thai food and hang out/chat for half an hour. Sometimes we got together and watched Harry Potter marathons on the fuzzy-screened box of a TV in the heme/onc signout room. A curmudgeonly older nurse would break character on Saturday mornings and make French toast at 4 am for anyone passing by. For one intern’s birthday, we raided the supply closet, made her a birthday crown out of the weirdest supplies we could find, and celebrated with ginger ale mocktails served in plastic pink cups at midnight.

Hope this is at all helpful to someone, and best of luck to all the new interns who started this summer and the sub-interns trying on this role for the first time!