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The Power of a Partnership

Nursing assistants Emilly Betty Niyonshuti, standing at left, and Hadijah Kabaganda, seated at right, wear face masks as they prepare for patient visits at Kisoro District Hospital last summer. (Photo by Aravind Addepalli)

The Power of a Partnership

Einstein’s global health program in Kisoro, Uganda, benefits both patients and students

By Teresa Carr

Last spring, residents of Kisoro, a remote district of Uganda, heard that a new illness called COVID-19 was approaching. They feared it would be like the Ebola virus—a death sentence that would wipe out people in hundreds of villages.

Kisoro hospital workers braced for an overwhelming flood of patients. They knew that the virus responsible for COVID-19 was easy to transmit. And in a society where six people might sleep in one room and go to the market every day, suppressing COVID-19’s spread was going to require some work.

Fortunately, a program for handling this kind of challenge was already in place, developed over the years by Kisoro District Hospital leaders, Einstein faculty and students, and the nongovernmental organization Doctors for Global Health. Ugandan village health workers—people who knew their neighbors best and had their trust—had been trained to deliver medical care to people in their homes.

Now, they traveled throughout the region to give half-hour talks using flip charts to explain how COVID-19 could be transmitted and how to prevent the illness. Working with four adults at a time, the workers reached more than 14,000 village residents in three months.

“People told us the home talk was the most valuable source for increasing their understanding of COVID-19, more than what they were hearing on the radio,” says Shombit Chaudhuri, a fourth-year medical student at Einstein who spent a year in Kisoro as part of a global health initiative.

The village health workers also began a home drug-delivery initiative so that older patients with chronic diseases could continue to take their medications and would not have to go to the hospital-based clinic and risk exposing themselves to COVID-19.

Slide
From left: Gerald Paccione Jr., M.D., rides with Sam Musominali, Einstein’s site director and head of the village health worker program; Vanice Ntambara, a village health worker, weighs a baby; and a view of the large, open rooms of Kisoro District Hospital. (Photos by Aravind Addepalli and Jill Raufman and courtesy of Gerald Paccione Jr., M.D.)

A Winning Partnership

Einstein and Montefiore’s connection with the people of Uganda began two decades before the pandemic arrived, with senior medical residents traveling to the western city of Mbarara to supervise interns and medical students at one of the country’s two medical schools.

Gerald Paccione Jr., M.D., a professor of medicine at Einstein, the director of global health education for the primary care and social internal medicine residency program at Einstein and Montefiore, and an internist at Montefiore, had been traveling around Uganda searching for another community with which to partner on sustainable local healthcare programs. Kisoro, in Uganda’s southwest corner, fit the bill. Though it is a breathtakingly beautiful region of mountains and dense forests, it is also a place of stark poverty, with per capita income of less than $2 per day and the highest prevalence of chronic malnutrition in the country.

Dr. Paccione launched Einstein’s global health partnership with Kisoro in 2005 with help from local hospital leaders, and since then some 15 Einstein medical students and 25 Montefiore residents have worked in the district every year, closely supervised by Einstein global health faculty members.

Students and residents first spend a month at Kisoro District Hospital, the only public (free) medical facility in the region, with more than 150 inpatient beds, and at the Chronic Care Clinic, which sees up to 200 patients a day. At the Chronic Care Clinic, students and residents work alongside Ugandans trained by the program to treat patients with hypertension, diabetes, chronic lung diseases, heart disease, neurologic disorders, and more.

Students then spend another month shadowing village health workers who deliver primary and preventive care to remote villages. (Like Mr. Chaudhuri and fellow fourth-year medical student Aravind Addepalli, some students will stay for a year.)

The program has grown tremendously since its creation 16 years ago. “We’ve invested in developing health resources in the hospital, clinic, and surrounding communities,” Dr. Paccione says. “In turn, those communities welcome our students, helping ensure that they receive top-notch medical training and have an excellent experience. It’s a win-win.” (See “Meeting Local Health Needs,” below.)

Slide
From left: A socially distanced group of village health workers discusses COVID-19; a microscope is used to analyze cell cultures; Gloria Fung Chaw, M.D., and senior translator Moses Dushime talk to a group of village health workers;  and Einstein fourth-years Aravind Addepalli and Shombit Chaudhuri take a coffee break. (Photos by Shombit Chaudhuri and Mark Scheflen)

Living and Learning in Kisoro

To prepare for their stays in Uganda, students and residents take an intensive monthlong global health elective. Still, says Alyssa Yeung, M.D. ’20, a Montefiore obstetrics and gynecology resident who spent much of 2019 in Kisoro, walking into the hospital for the first time was an eye-opener. “Wards are large, open rooms lined with basic bed frames topped with camp-type mattresses,” she says. “And families are expected to help take care of their relatives while they are in the hospital. On a nice day, you will see patients and their families out on the lawn, sharing a meal out of a common pot or doing laundry.”

From a clinical standpoint, one of the biggest differences from American healthcare facilities is the lack of diagnostic tools, says Gloria Fung Chaw, M.D. ’08, who spent years in Kisoro as a medical student, resident, and faculty member for the program.

“We have access to only four or five basic lab tests,” says Dr. Fung Chaw, an assistant professor of medicine at Einstein, an internist at Montefiore, and the associate director of the Global Health and Clinical Skills Fellowship program. “The ultrasound is old and often out of service. The X-ray machine functions only if you have film and electricity—and we were often without either.”

The challenging setting demands that clinicians pay close attention to their patients. “Students learn to rely on their clinical skills—talking to patients, doing a thorough physical exam, using clinical reasoning,” Dr. Fung Chaw says. “That’s not the type of medicine that is deeply taught in the United States, where we emphasize technology—sometimes to the detriment of both students and patients.”

Community care programs, such as Chronic Disease in the Community and the Elders Program, involve village health workers who visit senior citizens and those with chronic diseases at home, saving people the arduous trip to the clinic. Women’s health initiatives reduce mortality and foster healthier lives for women and their families. The women’s clinic and a community outreach program provide treatment, screenings for HIV infection and cervical cancer, counseling on family planning and domestic violence, postpartum care, and health education. Einstein students team with midwives to host a popular call-in radio program focused on women’s health. Nutrition programs feed infants in the pediatric ward and children in their homes. The programs help up to 800 children yearly, and the Ugandan parliament has recognized them as one of the country’s most effective nutrition initiatives. Treatment for psychiatric disorders, one of the leading causes of disability in Africa, is made possible. A health census collects demographic, medical, and behavioral information from people in the surrounding villages every two years to identify health risks. Patients with life-threatening heart conditions are referred to medical centers outside Kisoro equipped to care for them. Surgeries for up to four patients yearly are supported, and the program has a growing waiting list. The Follow-Up Project, involving a team of four trained staff members, reaches out by motorcycle to reengage with patients from remote villages who need continuous care but have stopped returning to the clinic—patients with tuberculosis, HIV, high-risk chronic diseases, and cervical cancer, and malnourished children. Educational scholarships help high school–age orphans and former employees pursue careers in healthcare. Meeting Local Health Needs Einstein and Montefiore have worked with partners in Kisoro to create an ever-expanding array of services:

Charles Moon, M.D. ’20, says he found it valuable to reach a likely diagnosis based on just the basic information available. “Coming back and practicing in U.S. hospitals now, I think I’m much better at that,” says Dr. Moon, who worked in Kisoro between his third and fourth years of medical school and is now a resident in pediatrics at Children’s Hospital at Montefiore. “I will be a better provider for my patients, no matter where they are.”

Dr. Moon is careful not to sugarcoat the difficulties faced by the villagers he cared for. “Life is hard there,” he says. “People come to the hospital with advanced cases of tuberculosis and rheumatic heart disease—things you don’t see much here in the States. People die because of a lack of access to medicines and modern surgical care. Sometimes there’s little we can do.”

Asked what they liked best about their time in Kisoro, Drs. Moon and Yeung both cited bumping along steep dirt roads on the backs of motorbikes as they accompanied village health workers on home visits. Since 2005, Einstein has trained about 80 village health workers, and most are still on the job. They work, on average, two days a week, educating people about topics such as nutrition and family planning, and monitoring discharged hospital patients, the elderly, and those with chronic diseases.

“The village health worker program is the foundation for a lot of community programs that have been developed,” Dr. Fung Chaw says. “One of the biggest accomplishments of our partnership has been training and supporting Ugandans who can provide important health services, particularly for chronic diseases. They connect with their Ugandan clinical supervisors when cases are complicated, and the supervisors, in turn, can take over on-site at Kisoro District Hospital or virtually. This is a unique infrastructure for delivering primary care and chronic-disease services in a rural district where resources are scarce.”

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From left: Fourth-year Aravind Addepalli prepares to distribute a box of medication with senior translator Moses Dushime; pills from the Kisoro Hospital pharmacy; and Jill Raufman, M.P.H., M.S., director of Einstein’s medical student global health programs, is surrounded by, from left, Christopher Pina, M.D. ’18; fourth-year Sadia Ahmed; Galit Benoni, M.D. ’20; Michael Kornblit, M.D. ’20; and fourth-years Akarsh Vijayashanka, Shombit Chaudhuri, Aravind Addepalli, and Shahaharyar Ilyas. (Photos by Shombit Chaudhuri and courtesy of Jill Raufman)

A Model for Global Health

The Kisoro village health worker program could be a model for improving health in resource-poor countries, research has shown. It is also a model many think would work well in underserved areas of the United States, including rural communities and urban areas such as the Bronx.

For example, Kisoro-area patients with high blood pressure who were monitored by village health workers maintained consistently lower readings than patients treated only in the clinic, according to a 2016 study published in Health Policy and Planning.

Thanks to the low cost of living in Kisoro, the village health worker program manages to operate on a modest budget. On average, village health workers are paid $250 to $300 per year, and Einstein and Montefiore participants volunteer their time. Einstein supports about 75% of the cost of student experiences through global health fellowships, with much of the money going to community projects the students participate in. Other funding comes from Karen’s Tots Fund (money raised for disadvantaged children through friends and family of Dr. Paccione in memory of his sister) and Hofstra University, a recent partner in the initiative.

Einstein and Montefiore’s long-term collaboration of more than 15 years with the people of Kisoro is a model for what global health can be, says Jill Raufman, M.P.H., M.S., director of medical student global health programs and associate director of the Global Health Center at Einstein.

“It’s a key reason why we have been able to develop successful programs and the infrastructure for healthcare delivery. Our current faculty were once Einstein students or Montefiore residents themselves,” she says. Ms. Raufman notes that Einstein will participate only in global health programs that are ethical, collaborative, and sustainable. “Our Kisoro model fulfills all of that,” she says. “Plus the people, who open their communities to Einstein’s young doctors in training, give as much as or more than they receive. It’s a real partnership.”

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