The Earth spans 24,859.82 miles from pole to pole. Before long, the reach of UF Health will too. No longer limited to solely serving Gainesville, the state or even the nation, UF Health educators, researchers and students are working in the global community more than ever before, solving global health problems and exchanging knowledge that will benefit the health of people at home and across the world.
By April Frawley, Morgan Sherburne and Elizabeth Hillaker Downs
In the rural villages and urban slums surrounding the Eastern tip of Lake Victoria in Kenya, it’s not unusual to walk three miles each day in search of clean drinking water. Sanitation is poor. Access to restrooms is limited. As a result, waste — from humans and animals — can pollute the water supply and environment, increasing the chances that people will contract diarrheal illnesses stemming from bacterial infections, such as E. coli, as well as viruses.
Globally, 1.7 billion people a year become sick with diarrheal disease and nearly 760,000 children under age 5 die as a result of its effects, according to the World Health Organization.
“We don’t think (in the U.S.) about water and sanitation, but there are over 2 billion people in the world who don’t have a safe place to use the restroom … as many as 1 billion people lack access to safe water,” says Richard Rheingans, Ph.D., an associate professor of environmental and global health in the College of Public Health and Health Professions and the Center for African Studies. “If you don’t have those services, it changes your life.
“This problem is just the tip of the iceberg. We are just beginning to understand that. If you think about each of those pieces — you don’t have money to pay to treat water, you don’t have money for the clinic if your kids get sick so they become more undernourished, which makes them more susceptible to illness, those same kids are also less likely to go to school — it’s a feedback loop for the poverty cycle.”
In July, Rheingans and a team of other UF researchers — including Kenya native Bernard Okech, Ph.D. — and graduate students were in Kenya, preparing to start a research project examining the socioeconomic factors that affect people’s access to water and the spread of enteropathogens, such as E. coli. For Rheingans, it’s one of several projects he’s worked on in Kenya and in other countries around the globe, including Tanzania, Nigeria, India and Mozambique.
He’s not alone. More UF researchers than ever are opting to conduct international research or incorporate elements of global health in their work, and the reasons are almost as varied as the countries where UF now has a presence.
“There are a dozen or more reasons why global health is so important, from economic reasons to national security to culture transformation, the global need and social justice … also there is a demand for it here. Faculty and students want to be involved,” says Linda Cottler, Ph.D., chair of the department of epidemiology in the colleges of Public Health and Health Professions and Medicine. “Global health initiatives strengthen other areas of science. In order to be competitive, we need to have a stronger presence in global health. In some large-scale collaborative studies, going beyond U.S. borders is required. There is a great need.”
One looks only to the current Ebola outbreak in Africa for an example as to why an understanding of and investment in global health has become such a crucial component of health care and research. Disease knows no boundaries or borders. And as our lives have become more mobile and global, students and experts alike must become prepared for and entrenched in these concepts as well.
“If you think back to the university’s land grant language, the goal was to create information to create change in people’s lives,” Rheingans says. “Back then, we were helping people a day away from Gainesville, which was a long ride away. It’s the same thing here, except now it’s a plane ride away. How do we catalyze change in real conditions on a broader scale?”
In this issue of The POST, we examine a few of the ways UF Health researchers, educators and students are doing just that — working to effect change across the world through research initiatives, educational outreach and programs that directly affect patients in need.
Mothers and babies in Haiti face the worst outcomes in the Western hemisphere and some of the worst in the world, according to UNICEF reports. Although organizations like Médecins Sans Frontières, also known as Doctors Without Borders, and other groups have helped by providing care and building a hospital, there still aren’t enough trained providers to deliver babies.
“It is only two hours from Miami, but it is like you are in a completely different world,” says Jane Houston, D.N.P., C.N.M., a clinical assistant professor of nursing.
To increase the number of trained midwives in Haiti, Houston is working with partners in Haiti to teach obstetrical skills to nurses and student-nurses. She will travel to Haiti in January to conduct the first training. She will also bring equipment nursing faculty can use to continue to build skills in nurses.
“One of the interesting things there is they have a family nurse practitioner program but they have no midwifery program,” she says. “Hopefully we can empower the faculty there to continue the training.”
Houston is not the only UF faculty member working to improve women’s health in Haiti. John Davis, M.D., director of the Obstetrics and Gynecology Residency Program, takes medical residents to Haiti each year to help gynecologists there through Queen of Peace Church and the St. Boniface Haiti Foundation.
“I get to teach and expose residents to surgical problems they might not face in the United States, and I get to be personally challenged by circumstances that are present in Haiti, like operating on very challenging patients in a resource-poor setting,” Davis said. “It’s the intangibles, the personal rewards, that are priceless.”
For Richard Rheingans, Ph.D., the simplest things in his work have made the greatest impact. One of his projects, a six-year grant, led to improved sanitation efforts at schools in Kenya. Rheingans’ team and others collectively influenced the nation’s Ministry of Education to increase the amount spent on soap and toilet paper for restrooms. These small improvements to hygiene go a long way toward stopping the spread of illness, he says.
“For me it is about being able to influence policy and program changes, “ Rheingans says. “Sometimes really small things make the biggest difference.”
However, Rheingans says the primary key to effecting change on a global scale is forming meaningful partnerships with local governments and universities. In almost every scenario where there is a global health problem, he notes that lasting change can only be implemented by those who live there, a sentiment soundly echoed by other UF faculty members.
Partnerships are crucial because not only do locals understand the cultural nuances at play, they are also the people who will be there long term. To sustain any sort of progress, the people who live there must be the ones driving the change.
“If we can work with the ministry of health (in a country) then they are more likely to use it and put the research into use,” he says. “You have to think about use as you are thinking about the research question.”
In addition to his work studying sanitation and water issues, Rheingans also is studying disparities in rotavirus vaccination, which can prevent some deaths from diarrheal disease.
Nestled in the Himalayas, bordered by China and Nepal, the remote Indian state of Sikkim has some of the highest rates of suicide, mental illness and substance abuse in India. The needs are great, yet there are few trained psychologists and psychiatrists there.
For 12 years, Linda B. Cottler, Ph.D., M.P.H., chair of epidemiology, has been working in India to expand research and training for mental health professionals to address these needs. She has been funded since 2001 through the National Institutes of Health Fogarty International Center with a training grant partnering with the National Institute of Mental Health and Neurosciences in Bangalore. Their work recently expanded to the remote areas of Sikkim and Assam.
Since becoming involved in global health research in 1982, Cottler’s projects have taken her everywhere from Haiti — her UF team is launching a study on non-communicable diseases there — to Taiwan — where they conducted research related to the effects of club drug use on the brain.
Soon, she will be directing the World Health Organization’s field trials for substance use disorders for the International Classification of Diseases’ 11th edition. Additionally, she is working closely with UF Health leaders on strategic planning for international health.
“There are more similarities than differences around the world,” Cottler says. “If you just look at a person and show you are interested, they will talk with you no matter where they are from.”
In Senegal, pregnant women and children run the risk of having both anemia and intestinal parasites. The rural countryside is impoverished, which makes it difficult for people to get proper nutrition. Close contact with herds of goats and sheep can facilitate the passage of disease between animals and humans.
A team of researchers from the College of Veterinary Medicine is working with Senegal’s Institute of Agricultural Research and its Ministry of Health to help improve the nutritional status of women farmers, their families and their livestock. Jorge Hernandez, D.V.M., Ph.D., a professor of epidemiology at the college, is leading the program, funded through a $250,000 grant from the United States Agency for International Development, which focuses in part on the empowerment of women in local economies.
The researchers have already visited Senegal three times to develop the study. Most recently, UF researchers delivered a workshop in epidemiology and basic instruction in data analysis to 18 health professionals employed with the Ministry of Health and Ministry of Agriculture.
The researchers will study two herds at two different sites. A family of about 25 tends a herd of 80 sheep and goats in a community called Empal, 250 kilometers northeast of Senegal’s capital, Dakar. The second site, 800 kilometers east of Dakar, includes a family of about 100 people who care for a herd of about 300. The researchers will also work with a health clinic in Empal that provides medical care to about 600 pregnant women and 1,200 children under 5.
In addition to hopefully improving the health of the women farmers, their families and their livestock, the program also will provide valuable experience to the four UF veterinary students who will join Hernandez in September. During this trip, field and laboratory work will begin.
“UF students receive state-of-the-art training. Now, let’s see how that can be applied in a very different environment,” Hernandez says.
In 2005, Karen Reed, M.S.N., DHSc, R.N., visited Vietnam and Cambodia with her husband as part of a medical outreach trip. As the daughter of a U.S. Army nurse and someone whose mentors had all served in Vietnam, she had always been curious about the area. She quickly fell in love with the people of Cambodia,
“The health care needs and educational needs were evident,” she remembers. “I started saving up to go back right away. I went back for two weeks in 2007 and realized it was not enough. I went for six weeks in 2010 and 11 weeks in 2012.”
In 2013, Reed received a Fulbright scholarship, which allowed her to spend 10 months teaching at a Cambodian nursing school and providing professional development to nurses and nurse leaders in the country.
Like Rheingans, Reed also feels she was able to make a difference through actions that sound relatively simple. For example, she took on the project of updating the nursing school’s library. Because many of these books are donated, school leaders didn’t want to throw them away. But some of the books were so out-of-date — like a 1948 book on caring for patients with diabetes — the information could have led to potential harm in patients. After earning the trust of leaders there she removed all books written before 2007. Also, she was able to secure $4,000 in new book donations and bought $2,000 in books paid for with Fulbright funds.
During her time in Cambodia, she also taught distance courses to UF students, allowing them to get a glimpse at the issues that affect health care there. Exposure to other cultures and global health efforts is crucial for students, she says, particularly in Florida.
“Florida is a multinational state and in this practice environment, exposure to other cultures and developing that framework for how you practice is a critical skill,” she says. “We are doing huge work in establishing connections across nations to help others and to also help our students.”
Dominican Republic, Yucatan, Ecuador…
Many students go on global health outreach trips and provide care for people in poverty. That’s good, said Sven Normann, Pharm. D., assistant dean for pharmacist education and international affairs in the College of Pharmacy. But Normann sees an additional benefit for these students: working with students in other disciplines under challenging conditions.
“The opportunity for various young health professionals to work side-by-side in a different environment is just an amazing experience,” Normann said.
The collaboration happens during annual trips over the students’ spring breaks, called “global health outreach” trips, namely to places such as Mexico, the Dominican Republic and Ecuador.
In one of these trips this year, students from the colleges of Medicine and Pharmacy traveled to the Dominican Republic to provide a week of health care. The UF pharmacists-in-training dispensed medicine, helped medical students understand pharmacist lingo, took blood pressure and tested glucose levels — all on their own dime. The college provides the medical supplies, but students buy their own plane tickets and pay for lodging, Normann said.
This isn’t the only overseas opportunity for UF pharmacy students. Normann and other faculty also lead intensive three-week sessions in various countries in Europe such as Finland, Ireland and Norway to study the way different health care systems work. Students also have the opportunity to complete their clerkships — the pharmacist version of a residency — in countries such as Spain, Italy and Malta, among others.
In the College of Nursing, another outreach trip to the Yucatan peninsula in Mexico is helping students learn not only about the health system there, but also about how to collaborate with students and health workers from another culture. While there, students work on a special project that changes from year to year.
“We immerse with the school of nursing in Yucatan and become involved in whatever they are working on,” says Jeanne-Marie Stacciarini, Ph.D., R.N., an associate professor of nursing.
This fall, the project yielded another success. A faculty member from the school in Yucatan, Universidad Autonoma de Yucatan, came to UF to earn a Ph.D.
In June, Liam Holtzman, D.O., landed 12,000 miles east of Gainesville in Chengdu, China, to spend the summer teaching medical students at the West China School of Medicine at Sichuan University.
One of several experts invited to serve as a visiting professor, Holtzman taught a mini-curriculum on acute trauma care and presented a course on sepsis management to the school’s faculty.
“This was an opportunity to get up close and see their medical education and make a meaningful contribution,” he says. “They have not had same evolution with trauma care that we have.”
The trip also afforded Holtzman the chance to learn from the students and faculty in China and gain more understanding about Chinese culture. China was one of the few countries Holtzman, a medical officer for the U.S. Secret Service, had yet to visit.
“Overall, it was a great experience — not only a bi-directional exchange of information, but friendships, professional associations and memories that will last a lifetime,” he says.
As an undergraduate biomedical engineering student volunteering in South Africa, Martin Wegman felt uneasy about the proposed solutions he was implementing in the settlements around Cape Town. He saw that many of the program’s diabetes education efforts left patients passive and dependent rather than empowered and that some would not be sustainable once the volunteers left.
“I think that’s my engineering background — a very consistent theme of my work is thinking on a systems level, seeing how intervening here or there is going to have influences throughout,” says Wegman, who is now an M.D./Ph.D. student in the department of epidemiology and conducts research in the Institute for Child Health Policy.
This eye for systems will be crucial as Wegman embarks on his next endeavor abroad through a Doris Duke Charitable Foundation International Clinical Research Fellowship. After several weeks of preparatory seminars at Yale University, Wegman arrived in Malaysia in August to help address a nexus of social, medical and mental health issues surrounding the prevalence of AIDS, tuberculosis and heroin addiction among a segment of Malaysian inmates.
In the 1990s, 80 percent of all new reported cases of HIV in Malaysia occurred among intravenous drug users, many of whom end up in jail for illegal substance use. While that number has since decreased, treating released inmates for HIV has proved difficult. Therefore, Yale professor Frederick Altice, M.D., and Adeeba Kamarulzaman, M.D., the dean of the University of Malaya Medical School, partnered to create the first methadone maintenance treatment system in the country as a way to treat recently released prisoners for HIV as well as for the TB contracted while in prison. The community clinics, which offer daily doses of methadone as well as medical care, were successful in trial settings, and now Wegman will assist in scaling up these efforts to more prison systems.
“The former prisoners need the methadone every day, so they stay engaged and they can get the care they need,” he says. “A piece that I can bring to this endeavor is to make sure we have the voices of the prisoners and families heard in this process. We need all the stakeholders involved there.”
Wegman’s experiences abroad will help him build upon his body of research at UF, which examines interventions with adults on Medicaid who have both mental and physical illness, and will further his goal of becoming a clinician-researcher in implementation science.
“I am just so eager for the added experience,” Wegman says. “It will be about immersion and trying to learn and unpack what’s really going on there, so if I ever do propose an intervention, I will be more informed. But I’ll also remember that I’m not the one driving it all. It’s the patients’ voices, the community voice that will drive it.”
Rwanda Kim Dunleavy, Ph.D., P.T., a clinical associate professor of physical therapy, is new to UF but she isn’t new to global health. Her involvement stretches back to her work in a rural hospital near the Mozambique border after earning her bachelor’s degree in her native South Africa.
While on the faculty at the University of Central Arkansas in the early 1990s, Dunleavy established a training program so rural residents could receive needed physical therapy in their own communities. A presentation she gave on the topic led to Dunleavy’s involvement with Health Volunteers Overseas and a USAID-funded project to update training in Vietnam for physical therapists.
She learned quickly that there was no one-size fits all for designing courses for providers in another country. Some of the therapists in the training course had no formal training at all.
Since then, Dunleavy has been involved in projects in Sri Lanka, Cambodia, Haiti and South Africa. She’s currently working on a new physical therapy training project in Rwanda. She will begin working in the country next year.
Getting global health on the same page
One of the issues related to global health that UF leaders are tackling is the coordination of global health studies and initiatives.
“There are tons of people doing global health, but it is not centralized,” says Sarah McKune, Ph.D., M.P.H., director of public health programs in the College of Public Health and Health Professions. “Global health means different things to different people.”
At UF Health, Cottler and other leaders from across all six health colleges, have been collaborating on strategic planning related to global health. And across UF as a whole, several new initiatives are now underway that are helping to bring the global health community together.
UF’s International Center established a Global Health Council to bring together people involved in global health and set goals and principles for engaging in global health initiatives.
Another program is a new global health case competition. This is bringing teams of students from across UF together to compete for a spot to participate in a national global health case competition at Emory University.
In addition, at UF Health, Amy Blue, Ph.D., associate vice president for interprofessional education, has established pre-departure training for students participating in health outreach trips to give them a cultural orientation before they enter a new country.
“The demand from students is huge,” McKune says. “There is a sense among this generation that we are a part of a global system. They want to be citizens of the world. With this mentality, students have a real drive to be involved. The students today have a different interest in the global good than people historically have had.”