Dr. Stanberry is the Reuben S. Carpentier Professor and Chairman of the Department of Pediatrics at the Columbia Vagelos College of Physicians and Surgeons, and Pediatrician-in-Chief of New York-Presbyterian Morgan Stanley Children’s Hospital. Our interview is focused on the establishment of a global health initiative in the department of pediatrics at Columbia University’s Medical School. Along with providing an enhanced educational experience, this program gives pediatric residents an opportunity to undertake a global experience that can be very valuable and influential to their future careers.
Novel Residency Training – The New Global Health Initiative | Dr. Stanberry | Transcript (via Sonix)
[00:00:01] Welcome to a new edition of What is Global Health podcast. Today We will be speaking with Dr. Lauren Stanbury. Dr. Stanbury is the Rubenesque Carpentier professor and chairman of the Department of Pediatrics at the Vagelos College of Physicians and Surgeons at Columbia University, and a pediatrician in chief of New York Presbyterian Morgan Stanley Children’s Hospital.
[00:00:25] His areas of clinical expertise include pediatric infectious disease, viral infection, immunization and sexually transmitted disease. Our interview is focused on the establishment of a Global Health Initiative and the Department of Pediatrics at Columbia University’s Medical School, along with providing an enhanced educational experience. This program gives pediatric residents an opportunity to undertake a global experience that can be very valuable and influential to their future careers.
[00:00:59] Could you describe the importance of merging the two vast fields of pediatrics and global health?
[00:01:06] Sure. Well, it’s sort of a logical thing to do when you look at the world’s population, two point two billion people on the planet are children. So we in pediatrics just view the entire world as our area of responsibility, caring for children wherever they happen to be online.
[00:01:26] And as stated, the department wants to assist regions and countries to become self-sufficient in educating health care providers and delivering care to their populations. How are you working as a department to accomplish this?
[00:01:40] Ok, great question. I think the perhaps best example is the work we’ve been doing in Uganda for the last 10 years. We’ve had a long collaboration with the Department of Pediatrics at Makerere University in Kampala. When we first started working with them, we met and had what’s referred to as a needs assessment, asking them what it was that we could help them with. And interestingly enough, the initial focus was on adolescent health, not on HIV or cancer, but adolescent health. You might think, gee, that doesn’t make much sense, but the reality of it is throughout all of Africa and certainly sub-Saharan Africa as well, adolescents, once a child reaches the age of 12 or 13, are no longer seen in the pediatric wards. They’re moved over to the adult wards. And we recognize that 17, 16, 15, 14 year old is not an adult. They’re a special age group that falls under the purview of pediatrics. And so our colleagues at Makerere University wanted help establishing an adolescent medicine program. The way we went about it was we had a colleague at Macquarie that was really interested in adolescent medicine, has some training, who was partnered with one of our adolescent medicine specialist, Dr Betsy Pfeffer. It’s Dr Sabrina Kotecki, who is the Ugandan who is matched to Dr Pfeifer. Those two started working along with Dr. Susan Rosenthal, who leads our division of Child and Adolescent Health, and Dr. Phil Roosa, who’s an infectious disease specialist with a lot of experience in Africa, came together and first began developing a curriculum where we could begin to educate people in Kampala at the medical school around what is adolescent medicine.
[00:03:39] We started an annual conference where we would go over and meet with them and talk about what they were doing in the area of adolescent medicine, brought in NGOs, non-governmental organisations from the region who are working with adolescents not always in health areas, but to get a sense of what else was going along in the country with regard to adolescents and start over years as we continue to bring more people into it, that they were gaining some real understanding of what adolescent medicine meant. Ultimately, we helped them establish the first adolescent medicine clinic in all of sub-Saharan Africa. And actually, with our support, established the only adolescent national and adolescent medicine society in all of Africa. So Ugandan Society for Adolescent Health, we now find that the meeting is a very robust conference. Each year, well over one hundred participants, it’s become more of a regional meeting. So we often see other physicians and health care workers who are interested in adolescent health coming in from Ethiopia, Rwanda, Kenya, Tanzania. So it’s been really rewarding in that regard to help them develop something they felt was really important along the way is that became a more mature program we revisited. What else do you need help on? And the most recent effort has been around sickle cell disease. So sickle cell disease is extremely prevalent in Uganda.
[00:05:17] And only recently is the government started a national screening program so that at birth, children blood samples were collected. So one can determine genetically whether a child is a carrier or is likely to develop sickle cell disease. We know from our work in the United States that one of the major problems with sickle cell disease is that early children and young adults can begin having small strokes sometimes that are not recognised. So the life expectancy of people with sickle cell disease is still very short. There are still children and parts of. Africa, the DYG and childhood. Whereas in the United States, life expectancy is probably only in the fourth or fifth decade of life, and strokes are one of the major causes of mortality in patients with sickle cell disease. So Dr. Nancy Green, one of our hematologist, partners with colleagues in Uganda to develop a project around how could we screen for strokes and whether interventions that could be used. It was a very successful project that showed that indeed children were having strokes from very early age. It’s a project that’s been now funded by the National Institutes of Health and they continue to expand that effort. Looking now to be able to use a drug that’s recently been shown to be effective at reducing the likelihood of cycling and hence the likelihood of a stroke. So we’re really encouraged by by that effort and we continue to evolve based upon what they feel they’re needed.
[00:06:57] So what motivated the development of the global health program and the Department of Pediatrics?
[00:07:03] So students, including our young residents, so interns and residents, our department is responsible not only for the training of medical students around pediatrics, but then once you graduate medical school, the training of residents who are going to become pediatricians. What we find is that from year to year, the interest around global health very substantially. Some years we find a very high proportion of students and residents are really interested in getting more engaged in other years. It’s not so popular. As a consequence, we’ve built the entire programs around the passions of the faculty, always with the ability to allow students and residents to have access to the programs. So in our case with you staying your doctor for a moment, we ensure that we’ve got a safe setting for them to be able to stay. And when they’re over there visiting or involved in research projects for obviously for students in the early years before they develop into clinical skills And the work that’s done globally is usually around a research project rather than learning clinical skills based upon what what opportunities are in a foreign country. But in Uganda, it’s we have a faculty member, Dr. Kudelski, who makes sure that the students are supervised and that they get a good experience, or if there’s a research project that’s ongoing, they’ll partner with the people who are engaged in the research on the ground in Uganda to participate in one way or another.
[00:08:46] Are there any general trends in regards to the students that are being observed since the assignment of this new program?
[00:08:53] So I think all of the students would say that they found the experience very enriching. We want to make sure they’re well prepared before they go abroad. So Dr. Nickless, who could not be here today for our medical students, actually has a very rigorous course that they take as an evening course so that they can learn about what it’s like to be in a foreign country, especially in a developing country. What are the issues around ethics, customs, so that a very prepared for it. And I think that’s really critical. One wants to avoid people who have an interest in what’s sometimes referred to as medical tourism or where they simply want to go in and look around and understand what’s going on. We’re looking generally for people who have a real commitment to serve the people who are hosting them. But the students and the residents who come back all tell me that they found it an experience. It was very moving that they felt even if they were not going to go to do global health, they have a much greater appreciation for populations who are under-resourced. And they often approach problems, perhaps slightly more practical way than they would have had. They not had that experience in a place like the United States where we are so resource rich, often you don’t try to keep things economical and focused, more inclined to just be perhaps excessive with regard to test ordering and drug administration. So overall, they feel it’s a very positive experience.
[00:10:34] What are some of the greatest challenges that pediatric residents have to face when working in developing countries?
[00:10:40] I think it’s a very good question. I think probably one of the biggest ones, believe it or not, is going to be the frequency with which patients die and those topics.
[00:10:52] So it’s not around. What’s it like to find housing or food like or transportation or personal safety? Those are all things that one needs to consider, but we see so little death in children’s hospitals in the United States because of our infrastructure, resources and the talents of the people who work in it, the nurses, doctors, respiratory therapist and so on. Death is a very uncommon phenomenon here, whereas in many developing countries it’s very common. And so they often find they’re really not prepared for that. And so I think making sure that they’re aware that there are life to death decisions that are made sometimes for purely economic. Some countries will have a formulary, and if the drugs that are required for the child are not part of the national formulary, the family has to find the money, go to the pharmacy, buy the drug and bring it back. And that’s not the kind of experience that most of our residents have. And as a consequence of understanding the systems that are available in different countries, they’re quite different often than what we have. And I think that’s an area that they find, at least initially, pretty challenging as an elective for residents.
[00:12:10] How has the global health program influenced their learning careers and global understanding?
[00:12:16] I think if I understand the question, it brings to them a perspective that they really did not have before. I also think it may well be more that’s probably the main difference, is that as a consequence of having that, their way of looking at patients in general changes somewhat a greater appreciation for the issue of resources, recognizing that even our own community resources could be limited for some families, certainly not around the drugs in all likelihood, but other kinds of limitations.
[00:12:52] And I suspect more than anything else, that’s probably the last.
[00:12:57] Do you find that typically after residents return, they may want to have more a broad experience?
[00:13:03] It’s a great question and it varies, although they may wish to during residency, at least in medical school as well. You’re a bit limited in how much time you have available to work on this. We find there are some. Residents who will go on and make a career out of global health and will work internationally, perhaps with Doctors Without Borders or with NGOs, others who, if they develop an academic career, will try to find a way to have a component of their career involving working abroad. And then sometimes we find that there are specialists who are just really passionate about a country or a particular problem, and they have the expertise to go on medical missions and spend time in foreign countries providing care. So it varies all over the place, but I think it’s an important introduction so they can have that. As a consideration of making career decisions, as you know, college and medical school and even in residency, you’re all a very. Growing organism, you you are gaining information about things you didn’t know before, and that informs the decisions you ultimately make. So I think having a global health experience is important for those people who are drawn to that, because it gives you one more piece of information that can influence exactly the ultimate career decisions and directions you make.
[00:14:43] Have you received any remarks or perspectives from the other side of the relationship, like the hospitals are the pit bull that the residents were serving during their time abroad?
[00:14:53] So certainly with our relationship with Makerere University and Mulago Hospital in Kampala, the feedback that we’ve gotten is that our students work well with the students who are medical students there in Kampala. They engage and really integrate into the rounds and in conversations. So I think they are also looking to form partnerships in that setting. And it looks like it’s a very reciprocal relationship. So it’s been a positive feedback also coming from your colleagues in Uganda.
[00:15:28] Could you share one of the most influential experiences you had of working in another country?
[00:15:33] My area, infectious diseases, and my work, among other things, on emerging infectious diseases, such things, for example.
[00:15:43] So we’ve had the opportunity to I’ve had the opportunity to to be in a lot of different parts of the world.
[00:15:51] for me recognizing that infectious diseases know no borders and can come from any place.
[00:16:06] Certainly for me, at least as a person of interest in vaccine development, making sure that anything we do that’s going to improve or protect the health of children in the US is going to be available to children around the world, is an important commitment to resources across the world, a very uneven issue. And the best approach from my perspective that we can do to improve human health, protecting children’s health is is going to be through preventative measures and making sure there is.