Professor Bill Bower
Image credit: https://www.publichealth.columbia.edu/profile/bill-bower-mph
In this episode of “What is Global Health,” Kyle Tong speaks with Professor Bill Bower about the training of lay health workers, the current Tuberculosis landscape, and Bower’s extensive experiences in global health.
Professor Bill Bower is a Special Lecturer in Population and Family Health at the Columbia University Mailman School of Public Health. With 19 years of experience in Latin America, Africa, and Asia, he co-authored essential guides like “Where There Is No Doctor.” In the US, he led TB education in New York City, creating pivotal treatment guides. Additionally, he directed training projects to enhance HIV/AIDS peer workers’ roles in New York City and designed tools for a project in Uganda aiming to improve TB and HIV management, underscoring his expertise in educational development and training for health initiatives.
Transcript:
Kyle Tong
Hello and welcome to the next episode of What is Global Health, a student-run podcast series by the Journal of Global Health at Columbia University. In this series, we interview experts in the field to learn more about topics ranging from COVID-19 to menstrual health and hygiene. We aim to factor all elements of identity, race, gender, sexuality, religion, and more into discussions of global health.
My name is Kyle Tong and I’m a first-year Columbia engineering student. I got to speak with Professor Bill Bower about tuberculosis health training and his experiences in health at the international scale. Let’s get started on this podcast. Could you please introduce yourself?
Prof. Bill Bower
Hi, my name is Bill Bower and I work in the Department of Population and Family Health at the Mailman School of Public Health.
Kyle Tong
Great. I know a lot of our listeners are interested in public health and getting involved. Could you talk a bit about how maybe you got started on this path and, and what decisions led you to be here today?
Prof. Bill Bower
I think I got involved in public health in sort of an unorthodox route in that I knew people who were volunteering with the nonprofit foundation in California that did health work in the mountains of Northern Mexico. And so I went and volunteered and was trained to be like a village health worker. And then I worked training village health workers and writing books about that and networking with other groups.
So I worked for 11 years with a network of community health programs in Mexico and Central America before I went to Columbia to become, you know, on staff in the Department of Population and Family Health and training of health workers, usually lay health workers, village health workers has always been what I’ve concentrated on.
Kyle Tong
Wow. Did you like, think that was where you’re gonna go, like outside of like when you went out of college?
Prof. Bill Bower
It’s interesting. I grew up in Venezuela. So I grew up speaking Spanish and I also had some health problems where I knew that the medical stuff wasn’t that hard to understand, but I didn’t think they were explaining it to me clearly. So I thought to myself that I could have, I have a skill that I can explain it in simple words in English and also do that in Spanish. So I was looking for a place to start out doing that. And working with this group in Northern Mexico was the opportunity.
Kyle Tong
That’s great. Do you have any like advice on, on people who are trying to navigate like the public health career field or anything like that.
Prof. Bill Bower
I would say that would constitute the old days when you still had outsiders coming in and actually providing health care because there was a lack of services, there were traditional healers and ways people dealt with things themselves, but health services were far away. And I would say now in most countries, the level of health services is higher, there are more trained staff And I think that outsiders can help more with ideas, program development, monitoring and evaluation and sort of developing the capacity of local groups to provide those sort of services for themselves. So things have evolved over time.
Kyle Tong
I see. And in regards to like after your work in Northern Mexico, how did you could you go over a bit how like your career developed after that?
Prof. Bill Bower
Well, after working in Mexico, I was invited to join the population and family health departments international training unit. And so we conducted training courses in sort of maternal child health, family planning. those sort of aspects of public health in mostly African countries, maybe six or eight African countries, also Nepal Haiti and other places. And we tried as in as many places as we could to develop a training team, a local training team that would carry on those training courses. So we did trainings in New York and then maybe six or more training courses in other countries and got those other groups going doing the training themselves to clarify.
Kyle Tong
Was this already like, were you already working specifically, like specializing with like tuberculosis or was this just more general training?
Prof. Bill Bower
It was more about identifying community needs and resources and then in the area, mostly of primary health care which you know, as defined by the World Health Organization, it’s like not hospital-based healthcare, primary health care, nutrition, family planning, safe Motherhood, immunization programs, oral rehydration to prevent people from dying from diarrhea. because they get dehydrated and family planning and contraceptive use all of those aspects of primary health care.
Kyle Tong
Did you find that these health care workers or lay health care workers are mostly like completely inexperienced or did they have like some base level where they were building off of?
Prof. Bill Bower
I would say they always had experience knowing their local context, the local myths, the local truths. what people believed, how things are done. And I think that we try to add to that with evidence-based solutions like oral rehydration or effective contraceptions or immunization programs or nutritious foods for kids, for weaning, whatever it might be as a primary healthcare intervention.
Kyle Tong
Would it be possible for you to give me like an example of that?
Prof. Bill Bower
Well, I’m thinking of a, an example and say in Sudan there were refugees in Sudan and we were working with a team of doctors to train people that would manage rural hospitals and the catchment areas around them. And we would go say to go to a refugee camp and measure to see what proportion of kids were malnourished or not. And then in order to prevent that, we work with local midwives who knew and, and had been taught nutritious foods that you can make with locally available ingredients. that will keep a child between say age six months and two years well-nourished with enough calories, protein and other micronutrients so that they’ll grow well and local people can teach that to others in practical ways. So we trained the doctors, doctors trained the nurses and midwives, nurses and midwives would do the workshops with people in the, in the refugee camps.
Kyle Tong
Oh, wow. Did you find that you usually this was like how you usually, like, you found a community with like a certain need and then you would address that by like like using it and like fusing in like the local community resources that they already had. or did you find that there was, this was like less of a common less of a common methodology and more often it was that you just applied like general general like advice or general resources to help, to help the population.
Prof. Bill Bower
I’d say we always tried to tailor the program exactly to the community. So when we did this sort of thing in Nigeria where like in a lot of West Africa, the marketplace is a very common place where people congregate, we would train people who sold products in the marketplace to be like the community health workers in Nepal. in different parts of the country, there would be I guess official community health workers, village health workers that were designated as part of the health system and we would work to enhance their skills. So in each place, you know, it would be different and the local beliefs, the foods available, the types of contraceptives or the types of treatments for malaria or whatever might be different. And so our training always would be adapted to, to that area.
Kyle Tong
Interesting. Yeah. Do you were like, was your work mostly in like helping them get set up with training or did you also like follow through and see like the effects of training like following the data of, of maybe the impact of what the training had and and like adapting off of that.
Prof. Bill Bower
It’s interesting that you bring that up. We did build in field follow up as part of our evaluation of training. So we would go back three, two or three months after a training course, we would go back to the field visit, trained people and see how are you doing? Tell us what you’ve done since you got back. What obstacles have you had? What successes have you had? What could be done so that you could more effectively u use the, the knowledge and the skills that you were trained to use. And then some of that, we could give technical assistance and advice right there in place. We would go with a local supervisor so that they could be backing that up and help with local solutions for it. But at the same time, if there were things that management needed to do or changes in policy, that would make things work better in the field, we would take that feedback and then back to the programs higher up. So we both tried to help right there in the field in a village in a small clinic or whatever it was as well as tell the people running programs higher up how they could back up the trained people. And then some few people ask about field follow up and that and that’s, that’s actually there are like four levels of evaluation of training and that’s one of the latter ones is to go and see how people are actually performing in the field and what you can learn from that. So, yeah, it was a very good question.
Kyle Tong
But could I ask the other steps of the, of the process? Out of the four?
Prof. Bill Bower
There’s a, the guru of training evaluation is someone named Kirkpatrick and he says the first level is, do you say you try to find out what are people’s reaction to the training? What did they like the most? What subjects do they, what did they learn that they can, you know, they can go and apply? What did they not like? just their satisfaction with the course? Second level is immediately after the course. What are the changes in knowledge, skills and attitudes? Third level is what are they doing on the job back out in the field? That’s the level that you were asking about? And then fourth level would be, what impact is it having on health on communities on other, you know, aspects of development. So, yeah, that’s, it’s a good model that a lot of people who evaluate training follow and obviously, it’s like a different scenario between like communities in need and like teaching students at Mailman.
Kyle Tong
But do you see you apply these similar like routines to your lecturing?
Prof. Bill Bower
That’s interesting. Definitely. in my training was personally face to face with students as well as through the course evaluations, we try to learn, how do people react to the course? Was it too long? Was it too short the balance of asynchronous or synchronous meetings? OK. Are the readings too much or is it too easy? Whatever it is those sorts of reaction to the course then gains in knowledge and skills, those are measured by our assessments or tests or you know, papers or you know, whatever we ask people to do. then what do they do in the field? There’s the difference between training and education in education. You educate people and then they go forth into life and that’s it. They’re gone. Whereas in training, you’re training people to do a job and they go back to doing that job or they go to doing that new job and you sort of, you know, work with them more afterwards. You can go and see what they’re doing. I honestly think that the School of Public Health does send questionnaires and these two students afterwards and more have like an alumni network where students can say this is my job. I’ve been promoted to this. These are the skills I’m applying, but it’s something that we’re actually looking at at doing. I’m on a, a core advisory group that’s trying to advise mailman on their core in the School of Public Health, the core, which is the first semester and we’re going to be reaching out to alumni. What did you learn? That’s the most useful, what was in the core, that was not useful? What do you wish had been done better and try to learn in that way? So that’s following up, say at level three, level four is what difference is it making in society that that’s often beyond, you know. Yeah, I haven’t been doing that.
Kyle Tong
That makes sense. Yeah. And sort of circling back to your work with like communities in need and like primary care. When did you decide? Or I guess what when it was the transition made to like go towards like specifying in like tuberculosis or HIV/AIDS from like primary care actions.
Prof. Bill Bower
Sure. I worked with the primary care training and stuff in Latin America, then in Africa, also in Bolivia and then I moved back to the United States and when I moved back to the United States, I was looking for a new job. And I knew Tom Frieden who worked with the department of Health in, as a commissioner for tuberculosis control in New York City. And I applied for a job in the education and training department unit that was there and I worked there for five years. It was really fun because I got to go deeply into tuberculosis. I knew some of it before because I had encountered it in other countries and trained health workers in general, how to deal with it. But I learned much more about it specifically and I helped guide the city’s health department, training and professional education and their educational materials about tuberculosis for another five years.
Kyle Tong
Did you or for our listeners who may not be as like knowledgeable? Could you explain a little bit about like tuberculosis and why it’s different from like, like influenza or other diseases.
Prof. Bill Bower
Ok. Something like the flu or measles. It’s easily catchable. You know, if we’re in the same room, the same elevator or something like this and you’re sneezing, you don’t cover your sneeze and all this. I could catch it. Ok. Tuberculosis is a slow-growing germ and you’re not likely to catch it from one sneeze or one cough. I think if we lived in an apartment building and we were a family and there were five of us and one of us was sick with tuberculosis and coughing. I think maybe two out of the five people there might catch tuberculosis from that person, but the others wouldn’t, it’s not like as instantly or rapidly spread. Also, it’s a slow-moving disease. I mean, it’s gonna attack more vigorously young kids, kids under two kids, under five. people who have diabetes, people whose immune system is weak if you have HIV or some other condition. but it’s a slow-moving disease. and different than influenza for which maybe there’s not a treatment because it’s a viral disease. Tuberculosis is caused by a mycobacteria, which means it grows slow. It doesn’t reproduce quickly. The, the antibacterial medicine that could fight tuberculosis can only be effective when the germ is multiplying. So you’ve got to take it for a long time so that any one of the germs you have in your body will have some time when they’ll be multiplying and then the, the medicines can get it. Otherwise your white blood cells will go and clean up and kill the rest. But, you gotta take a treatment which in some time in olden days it used to be, not, not that long ago in the seventies, maybe a year long treatment. Then treatments were nine months long. Then treatments are six months long. Now, treatments are four months long because there are better medicines for it.
Kyle Tong
And, how did you find, like, working with the New York, like Department of Health or a department of health? The, like landscape of, like, tuberculosis to be in, like New York or even, maybe like in the, the larger, like east coast area.
Prof. Bill Bower
Well, when I joined TB Control it was, it had just turned from its peak, it had almost like high 3000, 3800, 3900 cases in one year diagnosed in New York City. And so I helped train more people and to do good TB control work and drive the, the cases down. with tuberculosis control prevention is, and treatment are close because somebody with TB active TBD in their lungs, they’re coughing out the germs. They can spread TB to somebody, maybe, you know, one or two people a month until they’re, until they get treatment. So if you treat them, you’ll be preventing TB because they won’t be spreading it to others. So, treatment is prevention and tuberculosis. the other thing is that the medicines have to be the correct medicines and taken, I would say fairly carefully, they call it adherence. You’ve got to really stick to the plan of which medicines you should take how often and for how you really have to stick to that plan. And that’s why they use what’s called directly observed therapy where a trained person will watch you either in person or over zoom or in some sort of a, you know, supervised way watch to make sure you’re taking the medicines regularly. That’s the only thing that’s been shown to really make sure that people take the full course of treatment and then of course, taking a full course of treatment of the right medicines doesn’t allow resistant germs to emerge.
Kyle Tong
So, one of the reasons for like, why it’s so are so dangerous and like still like prevalent is the fact that it’s even when it’s like, not symptomatic, it’s being like spread throughout the however months or however many years, like the, the person spreading, it could be, could be like asymptomatic.
Prof. Bill Bower
Ok. Usually the person who would be spreading it does have symptoms, they’re sick, they’re coughing germs out into the public and that’s spreading it. However, other people who breathe those germs in, the first thing that happens to them is they will get an initial infection which their body can deal with. And then the germs kind of get latent it’s like the germs hide in your body encapsulated and that’s called latent tuberculosis infection. And that’s exactly what you said. It is asymptomatic. You are not sick, you feel nothing. You don’t have a cough, you cannot spread it to others yet. The germs are hiding in your body. And maybe in the fir, maybe 5% of people might break down with TB in the first couple of years. But then after that, another 5% will get TB later in their life. If they ever have a severe illness or their immune system gets weak or they’re just unlucky. So, yes, people who have latent TB infection are asymptomatic. People who have TB that’s active and they’re coughing, they can be spreading it to others.
Kyle Tong
Ok. And is that also part of the reason why, maybe when you think of like 3800 cases as being peak, it’s not that dangerous, but you still have to like, ensure that you’re like, clamping down to make sure that this doesn’t become like a, a ballooning like, or a domino effect later down the line.
Prof. Bill Bower
Yes, because usually, when somebody gets tuberculosis, someone goes and interviews them and explains to them about the disease and how important it is that they know that yes, it’s treatable and yes, they have to take the medicines regularly and get lab tests and also tell us who you’ve been breathing air with, who has been in enclosed places. With you since when you first started coughing until now. And so you come up with a list of contacts, people who likely breathe there with them. Usually it’s people where they live, where they work, where they have certain social activities. And so those people need to be examined to see if they have latent tuberculosis or not. And maybe a small number of them may also have caught, you know, have developed the active disease of tuberculosis. So you need to go and do a contact investigation. So you’re right, maybe for each person with disease, you may find on average five contacts or more that you need to examine. So, yeah, right there, you’re looking at a large number, you know, from 3900, you’re looking at maybe 20,000 people who are your contacts that you need to examine.
Kyle Tong
And then in so you have worked in like tuberculosis field as well internationally with like other other countries as well.
Prof. Bill Bower
Actually, only when I worked in Latin America, I would occasionally see people with tuberculosis and work with doctors or community health workers to follow up and make sure the treatment was there. I didn’t ever work with a program in tuberculosis control overseas except for once going on a mission to India to help assess training needs for training. And they had training of doctors, train training of treatment, supervisors, training of nurses, training of lab technicians to help in the diagnosis and all this and we had to determine what numbers of people needed to be trained, what skills they already had and where the gaps were and then what sort of training courses of what duration and all this and how many of them would be needed to gear up to improve the national program.
Kyle Tong
And, well, I guess given your, like knowledge of, like the disease and also, if you experience internationally, do you, would you be able to like, hypothesize? Why exactly we see that in America and other like developed nations TV, isn’t, it’s still like something that needs to be addressed, but it isn’t as prevalent as in, say, like, Africa or some other countries in the world where it is like, like an impending problem, maybe even like the, the leading cause of death in that country.
Prof. Bill Bower
I would say that, you know, one of the ways that public health has made a difference in life in the United States and, and many more developed countries is by having there be cleaner air, cleaner water, less crowded housing, better work conditions, better nutrition. So if your body is well nourished, if, where you live and work, the ventilation is good and you’re not crowded with people. If there are fewer people coughing, and all this, then there will be less of a disease like tuberculosis. so I, I think that in, in cases where people live in crowded housing where people are less, well nourished. then you’ll have more, you know, more tuberculosis.
Kyle Tong
And do you think, would you think that’s in conjunction with like treatment availability in, in these, in these parts of the world?
Prof. Bill Bower
Absolutely. Yes. I think in the United States, the CDC has done a good job of making sure that state and big city programs have adequate funding to deal with tuberculosis, given their configuration of state and you know, public and private health services to deal with the problem. Whereas I think a lot of other countries have trouble having adequate funding to deal with the problem, both the c the diagnosing of it, the treating of it and following up. And then once you’ve got that under control, then it’s really important to think about all those people with the latent tuberculosis. You’re not dealing with just the tip of the iceberg. That’s the people who are coughing and who are sick, but you’re dealing with people to whom it might have spread and who might develop it in the future. Now, there is a treatment for those people who have latent tuberculosis, but instead of taking four medicines for say six months or four months, they’ve got to take maybe one or two medicines still for, you know, a period of months, you know, and so, it’s again, much more effort to go around to people who feel healthy. They’re not coughing, they’re not sick but they still have to take a medicine for a number of months to prevent the chance of them having tuberculosis in the future. That’s harder to convince people. Is it? Yeah. How would you feel if somebody came to you and said, well, a test shows that you have a latent infection because you breathe the air. and we want you to take a medicine for six months or nine months.
Kyle Tong
I definitely would be, be more skeptical.
Prof. Bill Bower
Yeah, I might be skeptical you, if you had side effects, you might say, well, no, I don’t want to. And so yeah, that’s, that’s the challenge of, of really lowering rates is not only to deal with the tip of the iceberg, that’s the people who are sick with it, but also those who have the latent infection and, and in our, in our last couple minutes.
Kyle Tong
Do you have any if you could looking at like the tuberculosis like landscape today, what recommendations or what would be your like ideal future for how we manage and, and deal with the, the the disease in the coming years?
Prof. Bill Bower
Well, it may be pie in the sky because people have been working on it for a long time. But if there were an effective vaccination against tuberculosis, that could really help because once given to somebody, no matter how many doses it might require, then they would not get tuberculosis, would not get sick would not pass it to others and maybe it would eliminate the latent TB that they have.
So, an effective vaccination would make a big difference. I said right now, the, the immunization that there is, is called BC G. and what it does is it’s effective at preventing really young Children from getting the most deadly forms of the disease. So young kids won’t die of it, but it doesn’t prevent them from getting infected.
It doesn’t prevent them from getting sick. It just prevents the most deadly forms, in young kids. And it, yeah, and we need an effective vaccine for people of any age that will have them not get infected, not get sick, not be able to spread it to others. That would be great.
Kyle Tong
And, and like the research and development of the vaccine. Do you see it as like promising work or do you see it as more of like a dead end, endeavor?
Prof. Bill Bower
I think it’s gonna happen in my lifetime. I’m encouraged by having seen improved diagnostics. It used to be that some tests for diagnosing TB, took 36 or more weeks to give a result that you could make decisions because you would see what anti antimicrobial medicines, would be effective against the TB germ that somebody has or which ones wouldn’t be, that is now gotten down to fewer weeks or fewer days.
So the diagnostics are quicker and then in the last five years or more, there have been some powerful and well tolerated medicines that have shortened the treatment. Even the treatment for multidrug resistance, resistant TB, that used to be say a, you know, two year treatment, 18 month treatment, those treatments have been shortened to maybe only six months.
And the treatment for somebody with regular TB has been shortened maybe to four months. So shorter treatments means there’s less time for you to fall off the wagon and not take it. There’s less time and less cost for following up doing directly observed therapy to make sure somebody’s taking it every day. And the treatments are more effective. A higher percent of people achieve a cure from it.
So, because I’m encouraged at the development of diagnostics and new medicines, I’m willing to believe that a vaccine will, will come. It’ll be tough because the germ has a very waxy capsule on the outside of it and it reproduces very slowly and so whatever medicine or vaccine has, it’s got to act at that time that the germ is vulnerable. That’s tough. Let’s see.
Kyle Tong
Well, thank you so much on that. On that positive note, I think we’ll, we’ll finish the podcast. Thank you for coming. And, and I hope to, to potentially be able to talk to you in the future.
Prof. Bill Bower
Very glad to talk with you. Thanks very much.
Kyle Tong
Thanks for tuning in to this installment of What is Global Health? We hope you enjoy it. And as always be on the lookout for new episodes every other week, also, be sure to check out our online blog posts on our Columbia Journal of Global health website. And we’ll see you soon.