Author: FoG@rtY Page 9 of 10

Ronald Maio, DO, MS, FACEP founded and directed the University of Michigan Injury Research Center, and was PI for the Great Lakes Node of the Pediatric Emergency Care Applies Research Network. He is currently Professor Emeritus in Emergency Medicine at the University of Michigan Medical School.

On my recent trip to Ghana this past August, much of the country’s concern, and rightfully so, was focused on the Ebola crisis raging within its neighboring countries. However, the day before I returned to the US, the pernicious problem of death and disability from traumatic injuries, a problem that is my particular research interest and that of my mentees, came to the fore. There was a tragic road accident involving three mini-vans outside of Kumasi on the Kumasi to Accra Highway. Twenty-three people died and 11 others were injured. Twenty-one of those people were dead at the scene and two died in hospital. The dead and injured consisted primarily of young adults and children.

Death and disability from traumatic injuries, particularly road accident related injuries, have become a leading cause of death and disability in the developing world, and continue to be a major cause of death and disability within industrialized countries. The overwhelming majority of its victims are those that are in the early years of their productive adult life. As an emergency physician, a large portion of my training and practice focused on the evaluation and treatment of patients with traumatic injuries. My early research also focused on this area, but I eventually realized an important fact that the above described accident illustrates: most of the people that die from traumatic injuries, particularly road accidents, die immediately from catastrophic injuries. Most notably these are severe brain, cervical spinal cord and thoracic aorta injuries.

While I knew the importance of timely and high quality medical care for the injured patient, it became clear to me that I wasn’t doing enough. I needed to include prevention activities in my practice and in my research. My thinking was strongly influenced by the concepts of primary, secondary and tertiary prevention and the Haddon Matrix for injury control. This matrix can be applied to all injury events but was initially used for road accidents. It helps organize factors leading to an accident, and by filling the cells of the matrix one can develop both general and specific strategies for intervention.

At the time my perspective was broadening there were still many silos in the US addressing injuries from road accidents: it’s an engineering problem; it’s a policy problem; it’s a regulation problem; it’s a law enforcement problem; it’s a health behavior/ health education problem; and of course, it’s a medical problem. Thanks to the CDC’s National Center for Injury Prevention and Control and my early mentors and colleagues, I came to realize that death and disability from traumatic injuries is best addressed as a public health problem that requires co-ordinated multifaceted solutions. I began to collaborate with other Departments within the University of Michigan Medical School (UMMS) as well as the UM School of Public Health, the University of Michigan Transportation Research Institute, and the School of Pharmacy.

Although my research in acute trauma care continued, I also began conducting research on using computer technology to identify alcohol problems and intervene among the complete range of injured adults and adolescents presenting to the Emergency Department. An underlying concept was our perspective that a visit to the Emergency Department for an injury was a “teachable moment” to address risky behavior that could result in future injuries. Subsequently, my colleagues have expanded our work on alcohol problems to include addressing risk factors for inter-personal violence and seatbelt use. In the US, during the last 20 years, there has been a dismantling of the aforementioned “silos” and the growth of inter-disciplinary collaboration: essentially a team approach to the public health problem of traumatic injuries from road accidents.

As we help fellow global citizens in developing countries address the problem of traumatic injury in a sustainable fashion, we need to take a similar team approach. A great example of such an approach is the work that Dr. Charles Mock, a trauma surgeon from the University of Washington (UW), and his colleagues at the UW and in Ghana have been doing in the area of traumatic injury. Their work not only addresses acute clinical care issues, but also behavioral and environmental risk factors and is inter-disciplinary in nature.

We are fortunate to have the work of Dr. Mock and his colleagues on which to build and be informed, as well as his assistance with studies on quality of trauma care and also development of a trauma registry at Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana. These projects were headed and recently completed by Dr. Rocky Oteng, faculty in the UMMS Department of Emergency Medicine, during his Fogarty Research Fellowship. We are also conducting a project to determine the frequency of alcohol use and risky drinking among trauma patients presenting to KATH. This work is being conducted by a current Fogarty Fellow, Andrew Gardner, an M-3 at UMMS. We are also very fortunate to have the collaboration and co- leadership on these projects from the Director of Accident and Emergency (A and E) at KATH, Dr. George Oduro, and A and E faculty member Dr. Paa Kobina Forson. We think our work will have implications not only for acute clinical care but also for policy and prevention activities. We also think it will serve as a platform on which to further develop a sustainable research enterprise to reduce death and disability from traumatic injury in Ghana as well as the rest of Sub-Sahara Africa—and beyond!

My colleagues at the University of Michigan and our Ghanaian colleagues at KATH are very excited about our work and also very excited and proud to be part of the Global Team to reduce death and disability from traumatic injuries.

This article was originally published in the NPGH Fogarty Fellows October Newsletter

Including Men in Women’s Health

By FoG@rtY

On September 26, 2014

In Kenya, Research Spotlight

Fan Lee is currently in her 3rd year of medical school and has a background in cancer research and bioengineering. Her Fogarty project will be exploring the knowledge and attitudes of Kenyan men towards cervical cancer and their potential impact on cervical cancer screening at the University of Nairobi, Kenya.

Persistent bleeding after intercourse. That is what drove Mama Ruth to the hospital three years ago. She felt strong at 42 and there was no sickness – no fever, no pain, no fatigue, so she let it go unnoticed for months. She had heard rumors of a cancer that affects a woman’s parts, but thought the bleeding was AIDS. She has lived with HIV for over 13 years now, visiting the HIV clinic every first Tuesday of the month for her antiretrovirals. When the bleeding would not stop, she was sent on a three hour motorbike trip to town. “They said they could operate if I can pay. But they gave me nothing,” she said, “and no hope. They told me I had another disease of which there was no cure. Why would I let them cut me?”
Cervical cancer is a death sentence for too many women in low-resource countries. Since her diagnosis, Mama Ruth took on the role as a community health worker and single handedly brought cervical cancer screening to her district. Armed with a teaching flipchart she received at a visual inspection with acetic acid (VIA) training course, she and I spoke to women. For the handful recruited for screening, Mama Ruth would conduct VIA in spare rooms of the hospital, and then send women to the national hospital in town for removal of detected lesions.

Through this experience after my first year of medical school, I caught a glimpse of the day-to-day struggles women face and how these struggles impact women’s access to care. I heard about poverty and lack of transportation, poor facilities and limited trained personnel. But there was another discussion that emerged over and over again, one of stigma, society norms and gender disparities that affect the healthcare seeking behavior of women. Though it is important to be aware of resource limitations for successfully implementing women’s health services, we must also take into consideration the complex social dynamics that play a large role in a woman’s ability to make health decisions for herself. That is what I hope to explore in Kenya through a qualitative research study; to investigate the attitudes of male partners and their role in successful cervical cancer screening and treatment. I am fascinated by the nature of cervical cancer as a disease, and my experience working with women of East Africa has impassioned me to improve the health of women worldwide.

Gender power relations play a crucial role in sexual and reproductive health around the world. In patriarchal societies like Kenya, where male partners hold significant power over the health seeking behavior of family members, involvement of men is critical for the success of cervical cancer prevention programs. Our novel effort to engage and explore male partners’ awareness and attitudes towards cervical cancer screening will provide a critical perspective that will inform the development of interventions to engage partners not only in the screening process, but all aspects of female reproductive care. Potential interventions could be to incorporate partner counseling during screening, educational programs for men who accompany their female partners to follow-ups, peer education programs among men, or large-scale media campaigns to encourage male partner support. We believe that the more men are able to understand the implications of reproductive health and preventative care for their female partners, the more they will be able to provide encouragement and support. This study hopes to explore perspectives of not only women, but men, on the barriers to partner support as well as the actual and potential role as supportive partners in cervical cancer screening. This information will be helpful in developing strategies to implement sustainable interventions to include male partners in the cervical cancer screening process.

As a medical student, I cannot imagine a more exiting career than one that allows me to work closely with women at an individual and community level. It is a privilege for me to be a part of important intimate conversations with women and advocate for women’s health worldwide. I plan on pursuing an OBGYN residency after returning from this Fogarty year in Kenya and envision working with local health professionals to improve women’s access to health, develop effective treatment strategies and work with policy makers to implement culturally sensitive prevention and disease control programs. Ultimately, I hope to have the ability to think critically about the biomedical, behavioral and community aspects of healthcare and disease so that I can better serve my patients at home and abroad.

This article was originally published in the NPGH Fogarty September Newsletter