GMT20251008-155842_Recording_avo_1280x720

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Uploaded: 2025-10-08T19:12:57.0666667Z
Duration: 1 h 13 min 2 s

October 08, 2025

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04:29Okay. I'm gonna go ahead
04:30and get started as, people
04:31will be joining us in
04:32a moment.
04:33So, today is a treat.
04:35I'm looking forward to hearing
04:37a little bit. I'm gonna
04:38invite Bob in a moment
04:39to come up and formally
04:40introduce,
04:42professor Vadnassan.
04:43But first, just remind everyone
04:45that,
04:46encourage you strongly to, get
04:48your Grand Rounds credit.
04:50I also
04:53want to
04:55remind you can I expand?
04:57Can I go to the
04:58next slide here? Oh, here.
05:02What's coming up?
05:04Importantly, next week is,
05:08is the
05:10is the faculty,
05:12translational
05:13conference.
05:15Is that correct, Jeff?
05:17That is correct.
05:18And, and so I wanna
05:20remind everyone,
05:21to be present,
05:23be at the front of
05:24the room. It'll be more
05:25chalk talk,
05:27strategy, and, we're still developing
05:29that,
05:30plan. And and, this might
05:32be the right forum or
05:33we might choose a smaller
05:34forum. But for now, we're
05:35gonna bring lunch here and
05:37have everyone, and involvement.
05:41It's that's been a tremendous
05:43series, and we've integrated
05:44it. After, that, Sarah, is
05:47gonna do the next case
05:48conference.
05:50Mark Pelletier, who's our new
05:51chief of cardiac surgery,
05:52has agreed to come and
05:54introduce himself more formally to
05:55all of you and to
05:56hear about his work. He
05:58is the incoming,
06:00I think, program director for,
06:03ATS, and so he's very
06:05involved in in cardiac surgical
06:07societal and investigative work.
06:09Mark Petrie, who many of
06:11you have worked with and
06:12I've known for a very,
06:12very long time,
06:14is coming, and we're excited
06:15to have him here. And
06:16then we have an EP
06:18case conference by Gabriela. So
06:20pretty busy, schedule for next
06:21couple months.
06:23And then, with that, here's
06:25a disclosure and accreditation,
06:26and, ask Bob here to
06:28introduce our speaker. Thanks, Bob.
06:40Alright. Well, thanks, Eric.
06:42It's,
06:43my pleasure,
06:45to do this. Often, I've
06:46done this on people that
06:47I know very well.
06:49I can give anecdotes,
06:51but,
06:52I haven't had, the opportunity,
06:55to meet with,
06:56Raj, before today.
06:59But I can tell you
07:00when,
07:01I looked over his CV,
07:03which he's one of the
07:04people that you look at,
07:05you say, I wanna meet
07:07this guy.
07:09You know, it's one of
07:10those that the good is
07:11just not you know, good
07:13enough is just not enough,
07:15for him. You just gonna
07:16I can't go through the
07:17whole CV, but, you know,
07:19he got his bachelor's at
07:20Swarthmore and then he decided,
07:21okay. I'm gonna get another
07:22bachelor's,
07:23with his Marshall scholarship at
07:25Oxford.
07:26You know, goes to to
07:28medical school and, you know,
07:30kind of what I you
07:31know, trying to decide, oh,
07:32should I get a a
07:33master's kind of a research
07:35master's in Miles per hour?
07:36So what did he decide?
07:38I'm gonna get both of
07:38them.
07:40So he got went there.
07:41He goes on to
07:44the Brigham for training,
07:46in internal medicine,
07:48Sinai for,
07:50his red his cardiology,
07:52as well as faculty.
07:55And then now he's at
07:56NYU.
07:57And and also kind of
07:59the final thing I'll I'll
08:00talk about is he, you
08:01know, I don't think there's
08:03any part in science that's
08:04easy to to look into.
08:07But some of the ones
08:08that I think are more
08:08difficult,
08:10to do from a scientific
08:11standpoint, from a funding standpoint,
08:13from logistics standpoint,
08:15our global health is one
08:16of those. Health equity is
08:18one of those. Climate
08:19is one of those.
08:21So what does Raj do?
08:22I'm gonna look at all
08:23three of them.
08:25So this is something I'm
08:26very interested to to hear
08:28his talk, and to to
08:30meet with him,
08:31later on.
08:32Raj?
08:39Great.
08:41Thank you so much. Thank
08:42you for that very generous
08:44introduction.
08:44The problem with generous introductions
08:46is it's usually downhill from
08:47here. So,
08:49thank you so much, and
08:50and thank you to Eric
08:51for the invitation,
08:52and thank you to all
08:53of you for being here
08:54today. Wonderful to actually be
08:56here with old friends, several
08:58of whom I see in
08:58the audience as well as
08:59colleagues and folks I get
09:01look forward to getting to
09:02know better over the years.
09:04So my title of my
09:05presentation today is from cardiovascular
09:07care delivery to climate cardiology.
09:10Let me just see if
09:12I'm
09:14looks like the
09:15okay. Great. I'll just do
09:16it on the keyboard here.
09:19No corporate disclosures. These are
09:21the federal and foundation grants
09:22that I may refer to
09:23during my presentation
09:25today.
09:26However, what I wanted to
09:27start off with first is
09:29just a few cautionary words
09:30about engagement
09:31in global health.
09:33The reality is that our
09:34modern day practice of global
09:36health really actually was born
09:37out of the history of
09:38the last couple of centuries
09:40of, colonialism that, occurred around
09:42the world. And many of
09:44the aspects of that colonial
09:46history, you know, unfortunately not
09:47great, things like violence, things
09:50like forced displacement of populations,
09:51things like, extraction of resources,
09:54economic inequalities, etcetera,
09:56those vestiges still,
09:58reside within the current practice
10:00of global health. And so
10:02there are many folks who
10:03are trying to say, let's
10:04have a way to disentangle
10:05ourselves from some of that
10:07work, some of that history
10:08and some of those vestiges
10:09while still obviously doing important
10:11work around the world.
10:13One of my colleagues, Madhu
10:14Karpai from McGill, has written
10:16extensively about this issue, and
10:18I just wanted to read
10:19a couple of paragraphs from
10:20a blog he wrote a
10:21few years ago.
10:23Imagine this scenario, a couple
10:25of newly minted master of
10:26public health graduates from an
10:27African university, say, in Rwanda,
10:30land in Washington DC for
10:32a two week visit. They
10:33visit a few hospitals, speak
10:35to a few health care
10:35workers and policymakers,
10:37read a few reports, and
10:38write up a nice assessment
10:40of the US health system
10:41with several recommendations on how
10:43to fix the issues they
10:44saw. They submit their manuscript
10:46to the American Journal of
10:47Public Health.
10:48Can you imagine the journal
10:49even sending it out for
10:50review? Even if the paper
10:52got published somewhere, would US
10:53health researchers take it seriously?
10:55And then he puts on
10:56parenthesis, they should, I suppose.
10:58After all, the broken US
10:59health care system needs all
11:00the help it can get.
11:02Clearly, it's an impossible scenario,
11:04yet American graduates land in
11:06low income countries to advise
11:07them on global health issues
11:09all the time. I met
11:10an African expert recently, and
11:12she expressed her frustration
11:14about how American kids, quote,
11:15unquote, with little or no
11:16experience
11:18come all the time to
11:19advise her government on what
11:20to do about health. And
11:22so it's just a sort
11:22of, illustrative
11:24story, which actually happens a
11:26lot, more often than we
11:27would probably like to,
11:29admit
11:30about that reflects all of
11:32the issues that I was
11:32just describing, power and qualities,
11:34economic inequalities, resource and qualities,
11:36etcetera. And so the key
11:38message I wanna get across
11:39is not that these challenges
11:42should paralyze us, but that
11:43we need to be critically
11:44self reflexive of them as
11:46we try and disentangle ourselves
11:47from those challenges and move
11:49forward productively.
11:51With those cautionary words,
11:53stated, let me now move
11:55on to the content of
11:56my presentation.
11:57Cardiovascular
11:58disease is a global problem,
12:00and I just wanna know
12:01if my cursor okay. It
12:03doesn't come up onto the
12:04screen there. Okay. But,
12:06this is from the global
12:07burden of disease study.
12:09Each of the boxes, the
12:11square area of each of
12:12these these boxes is proportional
12:13to the number of deaths
12:14mortality burden around the world.
12:16Everything in blue are noncommunicable
12:18diseases, so cardiovascular,
12:20cancer, diabetes, kidney disease, etcetera.
12:23Everything in red are infectious
12:24diseases, HIV, TB, malaria.
12:27These data from twenty twenty
12:28one, obviously, COVID was huge.
12:30And then in green are
12:32accidents and injuries. And what
12:33you can clearly see here
12:34is that the blue doc
12:35blue boxes predominate,
12:37that the mortality burden from
12:39noncommunicable diseases are the largest
12:41burden of disease around the
12:43world. Amongst the noncommunicable
12:45diseases in the upper left
12:46hand corner are cardiovascular diseases.
12:49And amongst the cardiovascular diseases,
12:51number one and two, ischemic
12:53heart disease and stroke
12:55are the
12:58nice. Okay. Thank you so
12:59much.
13:01Combined ischemic heart disease and
13:03stroke, atherosclerotic cardiovascular disease, essentially,
13:06the number one cause of
13:07death around the world.
13:09Not only is cardiovascular disease
13:11a problem for the world,
13:12it's actually particularly a problem
13:14for what are called low
13:15and middle income countries. So
13:16this graph here basically shows
13:18along the x axis
13:20all these different regions of
13:21the world. High income countries
13:22here, the second, bar
13:25representing the United States, Canada,
13:27Europe, Australia.
13:28And what you can see
13:29here on the y axis
13:30are death rate per hundred
13:32thousand. Obviously, there's a lot
13:33of variability, but what I
13:34want you to focus on
13:35are these sort of, like,
13:36medium dark blue,
13:38which is cardiovascular mortality around
13:40the world. And what you
13:40can see here is that
13:41in many parts of the
13:42world actually
13:43that are lower income than
13:45high income country settings, cardiovascular
13:47mortality rate is actually higher.
13:49And so what has traditionally
13:50been thought of as an
13:51epidemic of high income countries
13:53or high income settings is
13:55actually more of a problem,
13:56you can argue, for low
13:57resource settings
13:59worldwide. What is the cost
14:00of cardiovascular disease globally?
14:03So this was put together
14:04actually over a decade ago
14:05now by the World Economic
14:06Forum and the World Health
14:07Organization,
14:09basically showing that,
14:11the estimated cost of these
14:12five groups of noncommunicable diseases
14:15would estimate cost the world
14:17forty seven trillion dollars over
14:18the next three decades.
14:20Importantly, a third of that
14:21coming from cardiovascular disease, nearly
14:23sixteen trillion.
14:25Very importantly, also sixteen trillion
14:27actually from mental illness. And
14:28so I'm not gonna speak
14:29about mental illness much more
14:30during this presentation today, but
14:32just recognize that it's an
14:33obviously huge source of both
14:35morbidity, mortality, and cost around
14:37the world. But as you
14:38can see here, a third
14:39of that forty seven trillion
14:41dollars, sixteen trillion dollars attributable
14:43to cardiovascular diseases around the
14:45world. Not only is it
14:47a challenge at the macroeconomic
14:49level, it's an economic challenge
14:50at the microeconomic
14:51or household level as well.
14:53So this was a compilation
14:55of studies from around the
14:56world basically looking at
14:58catastrophic health expenditures. And as
15:00you can see here along
15:01the x axis, there are
15:02different definitions of catastrophic health
15:04expenditures. Sometimes it's thirty percent
15:05of total household income, sometimes
15:07forty percent of capacity to
15:08pay. But the basic idea
15:10is that it's a significant
15:11percentage
15:12of a household or family's
15:13monthly income that goes towards
15:15health expenditures for noncommunicable
15:18diseases. And what you can
15:19see here on average around
15:20the world, you know, thirty
15:21to forty percent of households
15:23are experiencing catastrophic health expenditures
15:26due to noncommunicable diseases. And
15:28so just imagine even in
15:29your families if thirty to
15:30forty percent of your monthly
15:31income was going towards noncommunicable
15:34disease expenditures. It's a huge
15:36microeconomic
15:37household
15:38family level burden. Really not
15:40sustainable.
15:42Another way to think about
15:43cost. This was put together
15:44by Tom Gaziano from, Harvard
15:47where he looked at the
15:48cost of elevated blood pressure
15:49around the world and estimated
15:51it to be around four
15:51hundred billion US dollars per
15:53year, and treatment was about
15:55twenty percent of that cost.
15:57And, actually, eighty percent of
15:58the cost comes from untreated
16:00elevated blood pressure causing complications
16:02such as ischemic disease,
16:04stroke, heart failure, renal disease,
16:06etcetera. And so
16:08people will say to me,
16:09you know what? I agree.
16:10Cardiovascular disease is a big
16:11problem around the world. Yes.
16:13It's gonna be costly to
16:14the world, but you know
16:15what? It's too costly to
16:15treat. My response always is
16:17it may be costly to
16:18treat, but it actually is
16:19much more costly to not
16:20treat and allow the manifestations
16:23of complicated elevated blood pressure
16:25to manifest.
16:27What are the costs now
16:28of trying to address this
16:30problem? So here we traditionally
16:31divide them into population level
16:33interventions and household level interventions,
16:36individual level interventions. And
16:38at the population level, you
16:39can try and improve diet,
16:40physical activity, reduce substance use
16:42at the population level.
16:44And what you can see
16:44here on the top graph
16:46is that the order of
16:47magnitude is in the billions.
16:48So if you recall, cost
16:49of manifest disease was in
16:51the trillions.
16:52Cost of prevention now is
16:53in the billions, three orders
16:55of magnitude
16:56less. On a per capita
16:58basis in some low income
16:59countries, less than a quarter
16:59per capita per year. And
17:01so
17:02it's really not actually that
17:02expensive
17:03to engage in these population
17:05level interventions.
17:06Even when you move to
17:07individual level interventions where you're
17:09screening individuals for cardiovascular risk,
17:11screening people for cervical cancer,
17:13giving people a multidrug therapy
17:15for elevated cardiovascular risk, again,
17:17the cost is in the
17:18billions. And so if there's
17:19one lesson you walk away
17:20from today, my hope is
17:21that you'll recognize that the
17:22cost of manifest disease and
17:24all of the complications
17:26is much, much greater than
17:27the cost of early detection,
17:29early management,
17:30and control.
17:32Another debate that happens in
17:33the literature a lot is,
17:35should we focus on treatment
17:37or should we focus on
17:38prevention? And really the answer
17:39is both. This is a
17:41very elegant work by Simon
17:42Capewell and others from around
17:44the world where they looked
17:45at cardiovascular mortality
17:47changes,
17:48and sort of and and
17:49attributed either those changes to
17:50to changes in treatments, such
17:52as cardiac care units, cath
17:53labs, etcetera,
17:54or changes in prevention, lipid
17:56levels, obesity, diet, and whatnot.
17:58And what they were able
17:59to demonstrate fairly elegantly is
18:00that about fifty percent of
18:02the change in cardiovascular mortality
18:03are due to changes in
18:04and improvements in acute treatments.
18:06About fifty percent of the
18:07change is due to issues
18:09related to prevention. And so
18:10you really need both prevention
18:12and treatment efforts
18:13to be,
18:14going hand in hand. It's
18:15not shouldn't be a competition
18:16between the two.
18:18The challenge around the world
18:19is that there's a huge
18:20care gap. If you look
18:21around the world, this was
18:22put together by the World
18:23Heart Federation.
18:24Less than ten percent of
18:26individuals with the stroke are
18:27on evidence based therapy. Less
18:29than fifteen percent of people
18:30with myocardial infarction
18:32are an evidence based therapy.
18:33So there's a huge, what
18:34we call, care gap. And
18:36so people are not receiving
18:37actually evidence based therapy that
18:39we know should and can
18:40work. When you look at
18:42hypertension, you see the same
18:43thing. That the hypertension care
18:46cascade, you move from those
18:47who have, who have known
18:49who have hypertension,
18:51those who have ever had
18:52their blood pressure measured, there's
18:53the fall off. Those who
18:55have had their,
18:56hypertension actually diagnosed because it
18:58requires at least a couple
18:59of measurements, another fall off.
19:01Amongst those who are diagnosed
19:02as hypertensive, those who have
19:03been initiated on treatment, another
19:05fall off. And amongst those
19:06who have started treatment, those
19:07who are controlled. And you
19:08can see that along this
19:09entire care cascade, in literally
19:12every single region of the
19:13world, there's a there's a
19:14drop off in that care
19:15cascade. And so there's a
19:16huge care gap. What's the
19:18reason for this?
19:20Several reasons. Part of it
19:21is that there's poor availability
19:22of cardiovascular meds. So this
19:24was put, put together by
19:25Rasha Hatib and others,
19:27looking globally at different, income
19:29country settings. And what they
19:30showed was that in certain
19:32low income country settings in
19:34rural areas, the pharmacies don't
19:35even stock the medicines. Less
19:36than five percent of the
19:37pharmacies
19:38even stock cardiovascular medicine. So
19:40imagine
19:41that you're a patient with
19:42hypertension, cardiovascular disease. You go
19:44to the pharmacy to try
19:45and find the meds. Ninety
19:46five percent of those pharmacies
19:47don't even carry the meds
19:48that you need.
19:50Even when you go, to
19:52the pharmacy and you're able
19:53to find them, they are
19:54not affordable. So, again, the
19:56same concept of a capacity
19:57to pay, that same idea
19:59of a large portion of
20:00your household's family income going
20:02towards,
20:03these four very basic cardiovascular
20:05medicines,
20:07medicines, statins,
20:08ACE inhibitors, beta blockers, and
20:09aspirin. And what you can
20:10see here is that
20:11just these four medications
20:13in some rural areas of
20:14low income countries
20:15cost
20:16individuals and families nearly fifty
20:18percent of their capacity to
20:19pay. And so, again, I
20:20just want you to sort
20:21of go through the mental
20:21exercise of half of your
20:23monthly salary
20:24goes goes towards just these
20:25four medicines. I mean, it's
20:26obviously not a sustainable
20:28situation.
20:30The other challenge around the
20:31world is insufficient human resources
20:33for health. So this, heat
20:34map shows physician density relative
20:36to the population. Everything in
20:38the lighter colors means lower
20:39physician density relative to the
20:41population.
20:42And you can see here
20:43much of Sub Saharan Africa,
20:44a lot of South and
20:45Southeast Asia
20:47characterized
20:47by low physician density relative
20:49to the population, not enough
20:51doctors. If I were to
20:52show you a heat map
20:53of nurses, pharmacists, etcetera, it
20:55would also be very similar.
20:57The other challenge is the
20:58economic reality that populations face
21:01around the world. So these
21:02data come from our work
21:03in Kenya where we saw
21:05that seventy percent of our
21:07target patient population in rural
21:08Western Kenya was either unemployed
21:10or earning less than fifty
21:12US dollars per month. So
21:13essentially less than one dollar
21:14per day. So when you're
21:15living in that level of
21:17severe poverty, again, it makes
21:18it very difficult to do
21:20any of these things to
21:21try and access the doctor,
21:22purchase medications,
21:23transportation to the clinic, etcetera.
21:26We also looked at food
21:27insecurity
21:28food insecurity as a marker
21:30for economic vulnerability, and we
21:32were able to show that
21:33food insecurity is also associated
21:35with increasing difficulty accessing care.
21:37Again, so this idea of
21:39multiple,
21:40economic and, social challenges that
21:43that get in the way
21:43of people's ability to access
21:45care.
21:46When you expand yourself even
21:48broader, you think about climate
21:49change. Regardless of what you
21:51think think about in terms
21:51of ideology of climate change,
21:53the reality is that obviously,
21:54quote, unquote, climate is changing.
21:56It manifests in local,
21:59sort of severe adverse weather
22:00events,
22:02that then cause,
22:04sort of phenomena such as
22:06natural disasters, increased sea levels,
22:08differences in precipitation and temperature,
22:10ultimately leading to adverse health
22:13impacts.
22:13There's a very nice diagram
22:15actually from a recent article
22:16in the Scientific American where
22:17they talk about the cascade
22:19of climate change related health
22:20aspects. And I thought this
22:21figure was a very nice
22:23way of illustrating that cascade
22:24moving from climate hazards
22:26to secondary hazards as I
22:28described, wildfires,
22:29droughts, floods, etcetera,
22:31ultimately leading to changes in
22:33secondary hazards, water supply, food
22:35supply, and ultimately either long
22:37term or short term health
22:38outcomes, that sort of cascade
22:40of, health effects related to
22:41climate change. The important thing
22:43is you can't look at
22:44climate change in isolation.
22:46You have to look at
22:46the way that inter
22:48climate change intersects with what
22:49are described here in the
22:51bottom,
22:52green bar,
22:53social,
22:54behavioral, and environmental determinants of
22:56health. The conditions in which
22:58we live, in which we
22:59work, and in which we
23:00play that intersect with those,
23:02manifestations of climate change that
23:04then again lead to differential
23:05vulnerability
23:06to the effects of climate
23:07change. And when you look
23:08at vulnerability to climate change
23:11in terms of health effects
23:12around the world, you can
23:13see there's obviously a differential
23:14vulnerability to climate change around
23:16the world, which is very
23:17important to sort of keep
23:18in mind as well.
23:19So the idea really is
23:21to think about these social
23:22and structural determinants of health.
23:24Again, the conditions in which
23:25we live, the conditions in
23:26which we work, the conditions
23:28in which we play.
23:29That we are here at
23:30the sort of individual level
23:31health outcomes. Obviously, our lifestyle
23:33factors are affected by our
23:34community and social networks that
23:36are affected by our socioeconomic,
23:39sort of environment, culture,
23:40and even the natural environment,
23:42ultimately also impacted by the
23:44political context.
23:45This little cartoon that we
23:46put together, we were trying
23:48to show some of the
23:49data analytic challenges that are
23:51inherent in trying to study
23:53the impact of social determinants
23:54of health on, health outcomes.
23:57These little dots were basically
23:58to try and show that
23:59it actually is conceptually
24:01and from a metric perspective,
24:02actually quite challenging to actually
24:04define and create metrics for
24:06some of these entities. So
24:07for example, political context. How
24:08do you actually define it?
24:09How do you measure it?
24:10How do you put a
24:11metric to it?
24:12The other challenge is these
24:14little squiggly lines that the
24:15relationship is not linear actually
24:17across all these different levels.
24:19There will be sometimes feedback
24:21loops. There will be nonlinear
24:22relationships. And, again, from a
24:24analytic perspective, it can be
24:25very challenging. And finally, this
24:27delta t was to try
24:28and sort of illustrate that
24:29there's a temporal relationship also.
24:31There will be exposures in
24:32critical periods of one's life,
24:34whether it be in childhood
24:35or maybe even in utero
24:37that may not manifest until
24:38you're an adult. How do
24:39you actually analytically take into
24:41account those temporal,
24:43relationships? It's actually, again, very
24:44challenging.
24:46But if I were to
24:47stop my talk with just
24:48challenges, I would not be
24:50satisfied and neither would you.
24:51And so really the rest
24:52of my presentation, which is
24:54really a reflection of my
24:55work, has been about trying
24:56to translate the challenges that
24:58I've described
24:59into opportunities. How can I
25:00actually look at challenges
25:02and make things work for
25:03people despite the challenges that
25:05are there? I'm just gonna
25:06grab my water bottle.
25:16So this now
25:17brings me to my work
25:18in Kenya.
25:20Kenya, obviously, in East Africa,
25:21and our work was was
25:23in the western part of
25:23that country with an organization
25:25called AMPATH.
25:27AMPATH is an acronym that
25:28stands for academic model providing
25:31access to health care. Fundamentally,
25:33it's an academic global health
25:34partnership between academic medical centers.
25:37Their affiliated institutions of higher
25:39learning
25:40on either side of the
25:41ocean to try and advance
25:42the entire tripartite mission
25:44of academic medicine, care, research,
25:47and education.
25:48Empath started as a bilateral
25:50partnership between Indiana
25:51University and Moi University in
25:53Western Kenya. That was thirty
25:55five years ago. If you
25:56now fast forward thirty five
25:57years, that consortium has now
25:58expanded to include over fifteen
26:00different institutions,
26:02many of which are illustrated
26:03here. As you can see,
26:05Brown, Duke, Mount Sinai, NYU,
26:07Toronto, etcetera,
26:09all working collaboratively together
26:11to advance the tripartite mission
26:12of academic medicine, but to
26:14lead with care, to improve,
26:16care delivery, strengthen health systems,
26:19improve population health, and on
26:21top of that care foundation
26:22then leverage meaningful capacity building
26:24and research initiatives.
26:26We were one of the
26:27first groups on the continent
26:28of Africa to start a
26:29comprehensive age HIV care program
26:31in the early two thousands.
26:33Since that time, we have
26:34treated over two hundred thousand
26:35individuals living with HIV.
26:37I think we can lay
26:38claim that we were one
26:39of the first groups actually
26:40on the continent of Africa
26:41to convert HIV from a
26:42death sentence into a livable
26:44chronic disease.
26:45Over Over the past decade,
26:46we have then leveraged that
26:47HIV care infrastructure for chronic
26:49disease care, so more my
26:50wheelhouse, obviously, cardiovascular, hypertension, diabetes,
26:54cancer, mental health, etcetera.
26:56All the while thinking about
26:57strengthening health systems and all
26:59the while thinking about incorporating
27:01those same social and structural
27:02determinants of health into the
27:03care delivery initiatives that we
27:05have initiated.
27:06So I'm gonna be discussing
27:08some actually, this is not
27:10rocket science, except making it
27:11happen feels like rocket science,
27:13but there are very basic
27:14questions that I'm gonna be
27:15sort of showing you how
27:16we sort of step by
27:17step made this happen in
27:18Western Kenya.
27:19The first question was, how
27:20do we actually increase access
27:22to hypertension
27:23care
27:23for rural populations?
27:25The reality
27:26previously was that community members
27:29in the villages and rural
27:30areas would have to travel
27:31nearly a day to get
27:32to the district or referral
27:34hospital,
27:35wait there for another day
27:36to actually be seen by
27:37the clinician because there were
27:38so many patients trying to
27:39be, seen by a very
27:40small group of clinicians, and
27:42then another day to come
27:43home. So imagine every month
27:45needing to take three days
27:46out away from family, away
27:48from work, paying for transportation,
27:49paying for accommodation, paying for
27:51meals.
27:52So what we decided to
27:53do was to leverage actually
27:54dispensaries, which are small health
27:56facilities
27:57within these rural villages in
27:59Western Kenya, where nearly eighty
28:01percent of, patients with, you
28:03know, fairly easy to treat
28:04hypertension and diabetes, let's say,
28:06for example, could be managed
28:07there. And only those who
28:09are complicated or difficult to
28:10treat would actually then have
28:11to be referred up the
28:12system.
28:13What this would do is
28:14obviously improve the situation for
28:16community members and village members,
28:18but it would also actually
28:20reduce crowding at that central
28:21referral hospital. It would actually
28:23be beneficial for the health
28:24system
28:25overall.
28:26This situation is not unique
28:27to Western Kenya. I was,
28:29presenting this work in Montana,
28:31and they have the same
28:32challenge there actually where they
28:33have
28:34a a central referral hospital
28:36in the capital, but then,
28:37you know, they have a
28:38ton of people out in
28:39either the mountains or in
28:40the plains where it's actually
28:42very difficult for them access
28:43care. So this is not
28:44a Kenya specific problem. It's
28:45a problem that we face
28:46in many places in this
28:47country as well.
28:49In order to do this
28:50work properly, we have to
28:51actually address the entire health
28:53system for chronic disease management.
28:55So starting from level one
28:56down here at the bottom,
28:58working with, you know, household
29:00level grassroots workers, community health
29:02workers, etcetera, but all the
29:03way up to level six,
29:04which is the sort of
29:05in the public sector health
29:06system of Kenya where the
29:08teaching referral sort of center
29:09of excellence,
29:11was being established.
29:13Here, I wish to give
29:14a shout out to my
29:15colleagues from Kenya who were
29:16leading this work. Jamima Kamano,
29:18pictured on the left,
29:19a physician, endocrinologist
29:21who actually really started and
29:23led the chronic disease management
29:24program for many years. Her,
29:26nurse manager, Deborah Tulienge, who
29:28was with her for several
29:29years as well. And literally
29:30without their blood, sweat, and
29:32tears, I wouldn't be here
29:33together with you today. So
29:34I just wish to thank
29:35them publicly.
29:37The next question we had
29:38to ask ourselves was how
29:39to engage stakeholders from the
29:40top all the way down
29:41to the, villages. And so
29:43we had to actually get
29:44special permissions from the Ministry
29:45of Health
29:46nationally in Kenya.
29:48We went through all these,
29:49like, formal document signing ceremonies
29:51as you can see here.
29:52But a lot of the
29:52hard work actually happened out
29:54in the communities and out
29:55in the villages where you
29:56can see here are some
29:57of our staff actually traversing
29:59very challenging conditions to be
30:01able to reach individual homes,
30:02individual villages, speak with them,
30:04speak with their village chiefs
30:05and leaders to get a
30:06sense of what their priorities
30:08were, what their desires were,
30:09what their preferences were. But,
30:11again, I send this picture
30:12I share this picture here
30:13to show you these are
30:15the conditions our workers had
30:16to do, let's say, once,
30:17but our patients are having
30:19to navigate these conditions every
30:20single day. And so just
30:21a reminder of the challenges
30:23that people face on a
30:24daily basis in terms of
30:25their daily lives.
30:27So if you recall, I
30:28had talked about the challenges
30:29in medication supply. And so
30:31our question was, how do
30:32we ensure a consistent, secure
30:34medication supply?
30:35And here, I wish to
30:36give a shout out to
30:37my pharmacy colleagues who came
30:38up with a very cool
30:39innovation called the revolving fund
30:41pharmacy,
30:42where you take an initial,
30:43donation of medications or funds
30:45to procure a certain amount
30:47of, medications at the beginning.
30:49You stock those pharmacies in
30:50those rural areas as I
30:51was mentioning,
30:53improve access to medications at
30:54those rural pharmacies.
30:56They're able to sell those
30:57medications and generate revenue,
31:00to be able to continue
31:01in this sort of endless
31:02cycle of a revolving fund
31:04pharmacy where they're able to
31:06continue providing medications year after
31:08year after year. It's sort
31:09of like giving farmers seed
31:11in year one,
31:12allow them to plant, and
31:13then from their harvest, they're
31:15able to then continue this
31:16cycle of agriculture without the
31:18need for continuous external support.
31:21And what we were able
31:22to show is actually literally
31:23immediately after implementation
31:25of the revolving fund pharmacy,
31:27availability of medications at our
31:28pharmacies skyrocketed from before about
31:31thirty to forty percent as
31:32you can see here to
31:33literally immediately availability
31:35above ninety five to a
31:36hundred percent. And that availability
31:38we've been able to maintain
31:39for years since that time.
31:42This, picture here is just
31:44to show the experience of
31:45one year of that,
31:47work in a particular location.
31:49And so the way that
31:50this, picture works is we
31:51had three different models of
31:53the revolving fund pharmacy that
31:54we ultimately had to implement.
31:56We were really trying to
31:58address, as I mentioned, all
31:59six levels of the public
32:00sector health system from the
32:01very small health facilities all
32:03the way to the large
32:04teaching hospitals. And out of
32:05the far right are all
32:06the specific medications that we
32:08were able to distribute.
32:09What What we realized was
32:10that model one, which is
32:11our original model for the
32:12revolving fund pharmacy, did very
32:14well to supply the mid
32:15level facilities, level two, level
32:17three, level four facilities.
32:19Model two then was able
32:20to supply the larger facilities,
32:22five and six. But really
32:23to get to the small
32:24facilities, level one and level
32:26two, we had to iterate
32:27even further, and I can
32:28go into details if people
32:29are interested in terms of
32:30what arrangements we have to
32:31make. But, ultimately, we had
32:33to iterate and become contextual
32:35in terms of our solutions.
32:37But, ultimately, we were able
32:38to have delivered over six
32:40million doses of medications to
32:41a population that literally had
32:43zero the year before. So
32:44really a remarkable achievement
32:46by the pharmacy,
32:47team.
32:49The next question that arose
32:50was we have these small
32:51dispensaries
32:52in these rural villages staffed
32:54by nurses. So the question
32:55was can actually nurses lead
32:57hypertension management? And the reality
32:59in Kenya at that time
33:00and actually in many places
33:01around the world still to
33:02this day is that it
33:04is illegal for nurses to
33:06prescribe antihypertensive
33:07medications.
33:08They may be able to
33:09dispense them. They can educate
33:11patients, but the prescription has
33:12to come from a physician.
33:14And so to allow nurses
33:15to actually be the primary
33:16prescribers
33:17was something that we had
33:18to get very special, permission
33:20from the Ministry of Health
33:21in order to be able
33:22to show or test, at
33:23least, whether this is gonna
33:25be able to be done
33:25safely,
33:26and effectively.
33:28So pictured here is one
33:29of our nurses in front
33:31of one of these very
33:31basic dispensaries.
33:33It essentially has three rooms,
33:35one room for intake, one
33:36room for the physical examination,
33:38one room for storage of
33:39supplies. It's basically the size
33:40of the stage almost. You
33:41know? So imagine these are
33:43the clinics that we were
33:44working in in Western Kenya.
33:46And what we were able
33:47to show
33:48is that nurses were able
33:49to manage and control blood
33:51pressure just as effectively and
33:52with safety
33:53as their clinician counterparts. So
33:55shown here on red are
33:56patients taken care of,
33:58by nurses, and shown here
33:59in blue are patients taken
34:00care of by their clinical
34:01officer counterparts.
34:03And most of the blood
34:04pressure change actually happened in
34:05the first three months of,
34:07treatment, and that, blood pressure
34:08change was was equivalent between
34:10nurses and their clinician counterparts.
34:12And if anything, actually nurses
34:14outperformed
34:15their clinician counterparts in being
34:16able to maintain that blood
34:17pressure reduction over time. So
34:19we were really one of
34:20the first groups to show
34:22that nurses can do this
34:23safely, effectively in these low
34:25resource settings.
34:26The next question that came
34:27up was can we actually
34:28then support these nurses with
34:30technology,
34:31with mobile health, with digital
34:32health solutions, etcetera.
34:34So a quick detour in
34:35what I like to call
34:36design thinking.
34:38Design thinking in my head
34:39really is about complementing what
34:41we normally learn in school,
34:43in medical school, deductive and
34:44inductive reasoning with what I
34:46like to call abductive reasoning,
34:47thinking outside the box to
34:49rethink the problem in order
34:50to rethink the solution, but
34:52really getting into people's heads
34:53and lives and lived experiences.
34:56So my favorite example of
34:57this is, the classic elevator
34:59problem. You go to any
35:00medical center, I'm sure it's
35:01true here, you go to
35:02any, fancy,
35:04hotel, and there's always a
35:06a long wait at the
35:06bottom of the elevator banks.
35:08And you can try and
35:09do all sorts of solutions
35:10using engineering and, again, deductive
35:12and inductive reasoning. You can
35:13try and make them faster.
35:14You can make them more
35:15responsive.
35:16You can start them at
35:17level ten, whatever it is.
35:18But there's always a non
35:19zero wait. Then someone came
35:21along and said, you know
35:22what? Maybe waiting is not
35:23the problem. Maybe the problem
35:24is that people get bored.
35:26So let's address the boredom.
35:27So they put a mirror
35:28at the bottom of the
35:29elevator banks. Then all of
35:30a sudden, people are, like,
35:31combing their hair. They're doing
35:32their makeup. They're checking other
35:33people out, and the boredom
35:34went away. And what you
35:35see then is is that
35:36there was a proliferation of
35:38these mirrors at the bottom
35:39of all these fancy elevator
35:41banks at the bottom of
35:42these elevators.
35:43The reality these days is
35:44actually these, like, electronic screens
35:46with, like, news and sports
35:48and weather or whatever. But
35:49the same idea, rethink the
35:50problem in order to rethink
35:52the solution.
35:53So when we went to
35:55these rural dispensaries to train
35:57these nurses on hypertension and
35:59diabetes management, what we realized
36:00was that their lives were
36:01full of paperwork.
36:03Paperwork. Paperwork. Paperwork. They had
36:05to fill up paperwork for
36:05the clinic.
36:06They had to fill up
36:07paperwork, obviously, for the patient.
36:08They had to fill up
36:09paperwork for the district level,
36:11health system. They had to
36:12fill up paperwork for the
36:13National Ministry of Health. They
36:15have so much paperwork that
36:16they didn't even have room
36:17on their little tables for
36:18the small glucometers and blood
36:20pressure cuffs that we were
36:21trying to supply them with.
36:23So we came up with
36:24what we thought was a
36:24pretty cool solution, which was
36:26still paper based,
36:28which was to integrate all
36:29of this into one. Sort
36:30of clinical decision support, blood
36:32pressure tracking over time with
36:34an integrated record keeping system.
36:37Then this was actually at,
36:38at the time that,
36:40mobile phones were just being,
36:42developed and released. So iPhones
36:43and Androids, this is back
36:45in twenty ten, twenty eleven.
36:46So I don't know. Some
36:47of you were maybe not
36:48even born at that time.
36:49You know, were just being
36:50released. And so
36:52people thought, you know what?
36:53Let's try and put this
36:54onto the mobile phone. But
36:55there were some technical challenges,
36:57which now feels like, you
36:58know, sort of like old
36:59news. But the back then,
37:00it was quite revolutionary.
37:02If you typed in someone's
37:03age or someone's sex or
37:04gender into the phone, could
37:06you actually trust that the
37:07phone would would receive
37:08and replicate that same information
37:10back to you?
37:11Could you then subject that
37:12information to some smooth simple
37:14decision support? Let's say if
37:16the blood pressure was one
37:17seventy by one ten, that
37:18the machine would then spit
37:19back at you, okay, you
37:20should increase the dosage of
37:21medication. Or if the blood
37:22pressure was one ten by
37:23seventy, then it would say,
37:24you know, stay the same.
37:26And finally, could you sync
37:27that mobile device that was
37:29in these rural villages
37:30with the central server, which
37:32is at the main teaching
37:33hospital? So, again, these days
37:34with, like, Google Maps and
37:36this and that, it feels
37:37like, you know, like, why
37:38are you even asking this
37:39question?
37:39But back in the day,
37:40it was actually quite revolutionary.
37:42So happy to say that
37:42we were able to do
37:43that. We've obviously improved the
37:45user interface over time. This
37:46is version two point o.
37:47We're now at version four
37:49point o. But happy to
37:50say that we've been able
37:51to, again, sort of be
37:52at that leading edge of
37:53being able to use mobile
37:54technology
37:55for hypertension and chronic disease
37:57management.
37:58The next question we asked
37:59ourselves was, again, how do
38:01you incorporate those social determinants
38:02of health
38:05into hypertension care? And I
38:06will remind you what I
38:07showed you at the beginning.
38:08Seventy percent of our population
38:10was either unemployed
38:11or earning less than a
38:12dollar a day.
38:14That
38:15individuals with increasing food insecurity,
38:17and food insecurity was widely
38:18prevalent throughout this community, but
38:21increasing levels of food insecurity
38:22associated with increasing difficulty accessing
38:25care. So when you think
38:26about the social and structural
38:27determinants of health, what we're
38:28really focused on here was
38:30the socioeconomic,
38:31setting that people were living
38:32in, the conditions that they
38:33were living in. So we
38:35borrowed from our HIV colleagues
38:36who had already been addressing
38:38this problem, providing gainful employment
38:40opportunities to individuals living with
38:41HIV pictured here in textiles
38:44or here in agriculture.
38:45And over time, these have
38:47evolved into what are called
38:48guiche groups. Essentially,
38:50group what they call group
38:51integrated savings and health empowerment
38:53groups. Really self sustaining groups
38:56that come together
38:57where people,
38:58loan each other funds, pool
38:59funds together in order to
39:01be able to then pay
39:02off either commitment fees such
39:03as health insurance,
39:05school fees, etcetera,
39:06or be able to invest
39:07into their small businesses, poultry,
39:09etcetera,
39:10really to try and improve
39:11their economic situation.
39:13What our HIV colleagues saw
39:15was that these, self sustaining,
39:17microfinance groups were proliferating like
39:20wildfire because they were addressing
39:22conditions that people actually cared
39:23about, that they really were
39:25experiencing on a day to
39:26day basis.
39:27So we thought let's try
39:28and do the same thing
39:29for diabetes and hypertension.
39:31So this was our trial,
39:32BIGPIC, bridging income generation with
39:34group integrated care, where we
39:35brought together
39:37individuals
39:37living with diabetes and hypertension
39:39into these micro finance groups
39:41while they were there addressing
39:43concerns that they were interested
39:44in, which is their economic
39:45situation. Let's also now check
39:47their blood pressure, check their
39:48blood sugar,
39:49and treat them for their
39:51diabetes and hypertension ultimately, but
39:53with the thought of,
39:55reducing cardiovascular risk.
39:57So we went through our
39:57own human centered design process.
39:59We brought together people from,
40:01representing various,
40:03stakeholder groups, microfinance,
40:05nursing, village leaders,
40:07pharmacy, nutrition. Here was our
40:09visiting faculty from Duke, actually,
40:11David Edelman at the time.
40:13Anyone who's done, human centered
40:15design know that there's a
40:16lot of, like, color,
40:17coded post its, etcetera, that's
40:19involved with the process.
40:20We prototyped, we developed, we
40:22tested it out with the
40:23community, got a lot of
40:24feedback.
40:25And finally, we came up
40:26with our combined group medical
40:27visit microfinance
40:29model that we subjected then
40:30to a forearm cluster randomized
40:32trial.
40:33And what we saw in
40:34the unadjusted results was that
40:36actually this the combined group
40:38medical visit microfinance arm did
40:39lead to superior blood pressure
40:41reduction
40:42relative to usual care. The
40:43challenge was that because it
40:45was a forearm cluster randomized
40:47trial, we had to adjust
40:48for multiple comparisons.
40:49Once we did that, our
40:51our primary confidence interval just
40:53barely crossed zero. So I
40:54didn't have to satisfy ninety
40:56five percent confidence interval. We
40:57had to satisfy a ninety
40:58eight point three percent confidence
40:59interval. So, unfortunately, it didn't
41:01wasn't a total slam dunk.
41:03That being said, amongst those
41:05who either attended the groups
41:06actively in orange or those
41:08who had severely uncontrolled blood
41:10pressure at the at the
41:11beginning in gray did actually
41:13benefit substantially from the re
41:15intervention.
41:16And we've also shown that
41:17individuals with with cardiovascular
41:19risk were able to overall
41:20cardiovascular risk was able to
41:22be reduced significantly amongst those
41:24individuals as well.
41:26Our economist colleagues actually then
41:28went on to do a
41:29cost effectiveness analysis. And I
41:29think very importantly in terms
41:29of cost effectiveness analysis, many
41:30analysis. And I think very
41:31importantly in terms of cost
41:32effectiveness analysis, many times it's
41:34either a yes or no
41:35answer. Yes. It's cost effective.
41:37No. It's not cost effective.
41:38But I think very important
41:39actually is this concept of
41:41willingness to pay. Because depending
41:42on willingness to pay, your
41:44answer will be different. If
41:46you're only willing to pay
41:47a little bit of money
41:48down at the bottom,
41:49really then the answer is
41:51usual care. If you're willing
41:52to spend a ton of
41:53money, then the answer is
41:54the group medical visit microfinance
41:56model. And most people are
41:57gonna sort of land somewhere
41:58in the middle where maybe
42:00you just do the group
42:00medical visits without the microfinance.
42:02But the idea is you
42:03need to combine
42:04cost effectiveness analysis really with
42:07a concept of willingness to
42:08pay.
42:09The other thing we looked
42:10at were social network changes.
42:11If you bring together people
42:12in these groups and they're
42:13loaning each other money, can
42:15you increase a sense of
42:16trust? Can you
42:17increase a sense of cohesion,
42:19a sense of belonging?
42:21Will those social network characteristics
42:22then potentially lead to some
42:23of these blood pressure changes?
42:25And what we showed was
42:26that at the beginning, people
42:28were in these very weak
42:29and small networks in these
42:30dyads and triads as you
42:31can see here. And by
42:32the end, we had actually
42:33much more stronger interconnected networks.
42:36And we're in the process
42:36of doing those analyses now
42:38where it looks like network
42:39level variables were actually helping
42:41to contribute to some of
42:42the blood pressure changes that
42:44we've seen.
42:46The next question we've asked
42:47ourselves is how do we
42:48increase the,
42:49affordability
42:50of procuring hypertension medications?
42:53So as I mentioned, hypertension
42:54medications can sometimes be expensive.
42:56But what we realized in
42:57our population is that people
42:58were saving money for
43:00the procurement of those blood
43:02pressure medications,
43:03but what broke the camel's
43:04back was actually transportation to
43:06the health facility. That they
43:07didn't have the money to
43:08then go to the pharmacy
43:09or to the health facility
43:10to actually access the medications.
43:12And so what we saw
43:13here was that adherence was
43:15actually more related to transportation
43:16cost
43:17than actually due to medication
43:19costs.
43:20So, again, our pharmacy colleagues
43:21have come up with this
43:22cool,
43:24innovation called peer delivery of
43:26medications where a peer actually
43:28then
43:29is introduced to the patient
43:30at the,
43:31clinical appointment. And that peer
43:33then takes the, medication and
43:35actually delivers it to the
43:37patient at their home or
43:38in their village at a
43:39central,
43:40meeting point. And you're able
43:42to then again, now with
43:43technology, able to connect back
43:45to either the physician or
43:46the,
43:47pharmacist through teleconsultation
43:49to be able to do
43:50teleconsultation
43:51if necessary
43:52and reduce the frequency with
43:54which the patients have to,
43:56access medications at the facility.
43:58So you can go around
43:59and around in this cycle.
44:00And what we have shown
44:01is that as you increase
44:03the number of deliveries this
44:04way, you actually reduce,
44:06blood pressure and you improve
44:07their adherence score as well.
44:09And we're now subjecting this
44:10to a formal cluster randomized
44:11trial as well.
44:13The next question that always
44:14comes up is, okay. Fine.
44:16You're doing some interesting work
44:17in Kenya, but, like, what
44:18does it matter to us?
44:19Can these lessons in Kenya
44:20be applied elsewhere? And in
44:22particular, as you may have
44:23seen, many of these trials
44:24were funded by the NIH.
44:25And so the question is,
44:26what's the benefit to the
44:28US taxpayer? Can these lessons,
44:30be brought home? And I'm
44:31happy to say that the
44:32answer is yes.
44:34So this study, extra CBD,
44:36took place in Ohio and
44:38in North Carolina,
44:41and basically leveraged lessons directly
44:43from our learnings in East
44:45Africa.
44:46We were looking to improve
44:47cardiovascular risk amongst patients living
44:49with HIV in Ohio and
44:51in North Carolina.
44:53Nurse management,
44:54leveraged from East Africa. Mobile
44:56technology, leveraged from East Africa.
44:58Social networks, leveraged from East
44:59Africa. Africa. Process evaluation, leverage
45:02from our learnings, in East
45:03Africa. And so all of
45:04these things were brought to
45:06bear here for the benefit
45:07of a population in this
45:08country. We were able to
45:09show that this nurse based,
45:12management program for cardiovascular risk
45:14actually improved both blood pressure
45:15and lipids in these populations
45:17in in,
45:19North Carolina and Ohio. So
45:20this idea of reciprocal innovation,
45:22I think, is something that
45:23I think is very important
45:24to think about. This idea
45:25that there's a connection between
45:26the global and the local.
45:28There's a connection between rural
45:29and urban, between primary care,
45:30specialty care, between, importantly, academia
45:33and the community, and there
45:34can be learnings that go
45:35across
45:36all of these different, groupings,
45:37which I think is very
45:38important.
45:40The other way that we
45:40have leveraged lessons from Kenya
45:42is actually now expanding that
45:43whole AMPATH paradigm to other
45:45places. And so leadership of
45:46AMPATH Global said, we've done
45:48this work in Kenya. Let's
45:50now try and make it
45:50happen in other places. So
45:51NYU
45:52has been fortunate enough to
45:54be able to lead our
45:55AMPATH Ghana replication effort in
45:57Northern Ghana. We also have
45:58AMPATH Nepal,
46:00anchored by Mount Sinai and
46:01AMPATH Mexico anchored by UT
46:03Austin.
46:04And the idea behind AMPATH
46:05Ghana is that we are
46:06partnering with,
46:07University for Development Studies and
46:09the Thomley Teaching Hospital and
46:10the Ghana Health Service in
46:11Northern Ghana to do exactly
46:13the same thing that we've
46:14done in Kenya for the
46:15last three decades, advance the
46:16entire tripartite mission, lead with
46:19care, leverage that care foundation
46:20then for meaningful
46:22research and education.
46:24When I think of our
46:24work in AMPATH Ghana, three
46:26words come to mind, friendship,
46:29transformation,
46:30and equity. The idea is
46:31that
46:32all of our work with
46:33AMPATH
46:34leverages long term counterpart relationships
46:37and partnerships grounded in mutual
46:39trust, mutual respect, and mutual
46:41benefit. But it goes beyond
46:43just that. Really, we're trying
46:44to create
46:45transnational
46:45global friendships.
46:47We like to hang out
46:48with each other. We like
46:49to do things with each
46:50other. We celebrate each other's
46:51successes. We offer a shoulder
46:53to cry on when, like,
46:54you know, things bad happen
46:56that always happen with folks.
46:57So we really are moving
46:58beyond just professional relationships to
47:00now global friendships.
47:03We are leveraging these friendships
47:04and and relationships for transformation.
47:07So this now,
47:08I spoke a lot about
47:10the outpatient work that we've
47:11been doing in Kenya, but
47:12alongside that outpatient work was
47:13actually incredible amount of inpatient
47:16cardiovascular center of excellence work
47:17actually that doctor Velasquez
47:19helped to lead at the
47:21teaching hospital in Western Kenya.
47:23So this was the state
47:24of affairs in two thousand
47:25and five when I was,
47:27the medicine team leader for
47:28AMPATH Kenya.
47:29This gentleman came in fifty
47:31years old after having had
47:32equivalent of a donut at
47:34church,
47:35complaining of some epigastric pain,
47:37and for forty eight hours
47:38was treated with painkillers,
47:40h two blockers, proton pump
47:42inhibitors, etcetera. And finally, after
47:44forty eight hours, someone was
47:45like, hey. Maybe we should
47:46get an electrocardiogram.
47:47And when they did, it
47:48obviously showed that this guy
47:49was unfortunately, you know, suffering
47:51from a massive ST elevation
47:52MI. And for this unfortunate
47:54gentleman, he actually died within
47:55a half hour of that
47:56ECG being taken. That ECG
47:58obviously should have been done
47:59within five or ten minutes
48:00of arrival,
48:01but that was the state
48:02of affairs in two thousand
48:03five. Well, I'm happy to
48:05say after a ton of
48:06work and a ton of
48:08investment actually by,
48:09folks at Duke, again, under
48:11the leadership of Eric Velasquez,
48:12that, we've been able to
48:14transform cardiovascular medicine in Western
48:16Kenya. That in addition to
48:17all of the stuff that
48:19I described there, we've actually
48:20started a cardiology fellowship,
48:22and now the tray the
48:24sort of graduates of that
48:25cardiology fellowship are actually now
48:27the leaders of that cardiology
48:28division
48:29at that hospital. Felix Barasa
48:31is now the chief of
48:31cardiology. Wilson Saguet is the
48:34head chair of medicine.
48:35Konstantin Aquanalo leads the, electrophysiology
48:38program now in Western Kenya.
48:41We have Jerry Bloomfield, who
48:43is a colleague from Duke
48:44still there, who is, you
48:46know, doing a lot of
48:47stuff with advanced imaging here
48:48teaching transesophageal
48:49echocardiogram.
48:50And here, as you can
48:51see pictured here also invasive
48:53procedures. Pericardiocentesis
48:55is what we started with,
48:56but most recently, we've actually
48:57opened a cath lab as
48:58well. I was actually looking
48:59for a picture of Eric
49:00Velasquez because he had a
49:02he had a he showed
49:03off some of his, like,
49:04Latin dancing techniques one day,
49:06but I decided not to
49:07embarrass him. No. I I,
49:08but, we we had a
49:10we had a we had
49:10a great time together,
49:12and and really did some
49:13transformative work. But that same
49:15transformative work that we've done
49:16in Kenya, I have lived
49:18and breathed for two decades.
49:19So I know it's possible,
49:21but I know it takes
49:21time. But that is the
49:22same transformation that we are
49:24now embarking upon in Ghana
49:26as well. Leveraging the networks
49:27of practice within the Ghana
49:28health service to really implement
49:30a comprehensive population health program
49:33that includes both wellness clinics
49:34as well as chronic care
49:36clinics.
49:37That transformation is is extending
49:38to maternal health and sexual
49:40and reproductive health work,
49:41translating into,
49:43guidelines for, mental health and,
49:45hypertension and diabetes,
49:47and transformation for of molecular
49:49medicine
49:51installed a molecular diagnostic laboratory
49:54that promises to transform molecular
49:55medicine in the country of
49:56Ghana over the next two
49:58decades. So that transformation is
49:59something that we are working
50:00for. Not only are we
50:02transforming
50:02the way Ghana is gonna,
50:05implement its health services, we're
50:07transforming
50:08global health the way that
50:09we practice global health at
50:10NYU and transforming global health
50:12practice in this country as
50:13well. And so that is
50:14a very
50:14active,
50:16part of that activity as
50:17well. Not just transformation on
50:18that side of the ocean,
50:20transformation on this side of
50:21the ocean. And I think
50:22very importantly, those of us
50:23who do this work in
50:24a in a very sort
50:25of, sort of focused manner
50:27recognize that there's an internal
50:28transformation happening as well. Whether
50:30you call it psychological, whether
50:31you call it spiritual, whatever
50:32it is, there's a transformative
50:34journey that we are all
50:35on. And so that internal
50:36transformation
50:37is equally important as well.
50:39All of our work is
50:40informed by equity as well.
50:42Equity, what I like to
50:43call equity in process, as
50:45well as equity in product.
50:46All of our work is
50:47done in a counterpart collaborative
50:50fashion. That's true from the
50:51executive leadership all the way
50:53down to individual projects. So
50:55at the executive leadership level,
50:56we have collaborative partnerships between
50:59NYU, University for Development Studies,
51:01Tonglen Lake Teaching Hospital, but
51:02every single project, whether it's
51:04care, education, or or, research,
51:07all involves collaborative partnerships amongst
51:09those different,
51:10institutions
51:11as well.
51:12We're dealing with equity and
51:14we're addressing equity and product
51:16as well. We're not, again,
51:18just,
51:19comfortable with documenting disparities and
51:21there are many in country
51:22disparities in Ghana as pictured
51:24here in Northern Ghana,
51:26fewer physicians for the population,
51:28higher infant mortality ratio.
51:30But again, we are not
51:31interested in just,
51:33documenting
51:33those disparities but really trying
51:35to address and reduce those
51:37disparities. Shown here, climate vulnerability
51:40in Northern Ghana is greater.
51:41Food insecurity in Northern Ghana
51:43is greater. So all of
51:44our work is really informed
51:45about trying to address equity
51:47and product as well.
51:49So
51:51I'm gonna pivot a little
51:52bit here in the last
51:53few minutes.
51:54As I was driving to
51:55all these rural clinics in
51:56Western Kenya, I would often
51:58pass houses like this where
51:59you could see smoke emanating
52:00from the house.
52:02And in my head, I
52:02kept thinking, wow. If I
52:03can see this much snow
52:05smoke coming from outside the
52:06house, what must it be
52:07like living inside the house?
52:08And so it really got
52:09me thinking about
52:10household air pollution. And, again,
52:12going back to this diagram
52:13of the social and structural
52:14determinants of health, really here
52:16now thinking about and, addressing
52:18the natural environment.
52:20So then colleagues of mine
52:21and I said, listen. Let's
52:22actually try and quantify
52:24the burden of air pollution
52:25on cardiovascular health. And what
52:27we realized, and this was
52:28actually several years ago, was
52:29that combined indoor and outdoor
52:31air pollution
52:32was actually
52:33attributing or or sort of
52:35contributing to cardiovascular mortality
52:37at the same level as
52:39traditional risk factors that we
52:40think about, cholesterol, sodium, glucose,
52:43etcetera. So we were like,
52:44you know what? Air pollution
52:45needs to be on that
52:46map.
52:47And if you look now
52:48at the most recent global
52:49burden of disease study, air
52:50pollution is now on the
52:52map. Air pollution now recognized
52:53as the number two leading
52:55risk for
52:56death around the world just
52:58behind high blood pressure.
53:00And as a result of
53:01both the science and the
53:02advocacy, we were actually able
53:04to convince the World Health
53:05Organization to include air pollution
53:07as a major risk factor
53:08for noncommunicable
53:09diseases as well. Before,
53:11World Health Organization used to
53:12have four major risk factors,
53:14diet, tobacco, alcohol, and physical
53:16inactivity.
53:16And as a result of
53:17our work, we're actually able
53:19to advocate for them to
53:20include air pollution
53:21into that formulation
53:22as well.
53:24The reality, as I'm sure
53:25many of you know, is
53:26actually that air pollution the
53:28major cause of mortality from
53:29air pollution is actually cardiovascular
53:31mortality. Everyone thinks about the
53:32lungs. Everyone thinks about cancers.
53:34But actually, ischemic heart disease
53:35and stroke combined are the
53:37number one cause of death
53:39from air pollution exposure.
53:41There are many,
53:42mechanistic pathways,
53:44that I don't have time
53:45to go into today, but
53:46that you connect air pollution
53:48exposure
53:49to vascular dysfunction and ultimately
53:51cardiovascular outcomes both acute and
53:53chronic.
53:54And so, again, my,
53:57sort of MO is never
53:58to document problems, but to
54:00really think about solutions. What
54:01could I as a cardiovascular
54:02clinician
54:03do in the context of
54:04air pollution which feels like
54:05this big massive mega problem?
54:08And so at a minimum
54:09level, in my clinic, I
54:10was able to do risk
54:11assessment and really think about
54:13populations who are either highly
54:15exposed,
54:15those and this we did
54:16in the context of wildfire
54:18smoke, but you can imagine
54:19it being done for any
54:20air pollution exposure.
54:21Those who are highly exposed
54:22to air pollution or wildfire
54:24smoke and those who are
54:25increased, like,
54:27differentially susceptible to the same
54:29level of exposure.
54:30Those with pre,
54:31preexisting comorbidities,
54:34target age groups, pregnant women,
54:36etcetera.
54:38The next thing I, asked
54:39my colleagues in India was
54:41how can we try and
54:42address household air pollution?
54:45The reality is that over
54:46the last decade, there have
54:47been a lot of work
54:48done on improved stoves, improved
54:50ventilation, even trying to deliver,
54:53liquid petroleum, sorry, LPG, liquid
54:56propane gas
54:58to,
54:59rural populations. None of those
55:00have actually reduced household air
55:02pollution enough to really be
55:03able to translate into beneficial,
55:05outcomes.
55:06So one of the things
55:07that we're trying to do
55:08in India now is,
55:10install air purifiers in people's
55:12homes to try and improve
55:13cardiovascular
55:14health.
55:15We've been able to show
55:16that these air purifiers
55:18actually decrease air pollution levels
55:20down to the levels that
55:21actually may be to now
55:22improve cardiovascular health.
55:25And we're doing the study
55:26now in three cities in
55:27India,
55:27Delhi, Ludhiana, and Thiruvallantaparam
55:30that each have different levels
55:31of outdoor air pollution ambient
55:33exposure. And so the question
55:34we'll be asking ourselves scientifically
55:36is, do these indoor air
55:38purifiers have a differential impact
55:40depending on what your outdoor
55:41ambient exposure levels may be?
55:43So we'll sort of get
55:44a sense of that,
55:45as the trial unfolds. We're,
55:47just starting enrollment this year.
55:49And so, hopefully, in the
55:50next couple of years, we'll
55:51have answers for the for
55:52the public community.
55:53When you think about protecting
55:55cardiovascular health, this is from
55:56wildfire smoke, but, that we
55:58wrote about, but you can
55:59think about it from indoor
56:00or sorry, from air pollution
56:01exposure in general. Really think
56:03about not just individual level
56:04interventions, which I've just described,
56:06but also health system level
56:07interventions and also community level
56:09interventions. Again, both preventive in
56:11terms of preparing for exposure
56:13as well as, management in
56:15terms of how do you
56:16manage things when thing when
56:17individuals have been exposed already.
56:20You think even more broadly
56:22from air pollution and wildfires
56:23to what are causing some
56:24of these issues and really
56:25think about climate cardiology. And
56:27so we coined the term
56:28climate cardiology to think about
56:30interventions that could be co
56:31beneficial
56:32for both cardiovascular health as
56:34well as for climate change.
56:35And so many of these
56:36interventions, transitioning from high red
56:38meat to plant based diets,
56:40increasing green spaces,
56:42transitioning from vehicle or to
56:43active transportation,
56:45transitioning to clean renewable electricity,
56:47providing clean stoves and fuels,
56:49and air purifiers as I've
56:50mentioned,
56:51thinking about resource efficiency and
56:53health care, which is very
56:54important. All of these
56:55can reduce cardiovascular,
56:57morbidity
56:58and mortality and may also
57:00be able to improve the
57:01situation with respect to climate
57:02change, so it can be
57:03co beneficial, which is important.
57:06Thinking about climate resilience at
57:07a larger level, thinking about
57:09the WHO
57:10building blocks that they put
57:12forward. There are six building
57:13blocks that the WHO has
57:15put forward, leadership and governance,
57:17health financing,
57:18health workforce,
57:19access to medications and diagnostics,
57:22service delivery, and health information
57:24systems. All of these six
57:25building blocks can actually now
57:27be thought of from the
57:28lens of climate resilience. How
57:29can you actually
57:30incorporate climate resilience
57:32into the design, development, and,
57:35construction of both health systems
57:37as well as health care
57:38facilities. So that's the sort
57:39of next sort of phase
57:41of stuff that we're sort
57:42of actively thinking about in
57:44Ghana as well as throughout
57:45our global networks.
57:47A quick final word about
57:49proactive
57:50versus reactive prevention. So this
57:52was put together by some
57:53colleagues and I really thinking
57:55about
57:56trying to be more proactive
57:57with our prevention efforts rather
57:59than reactive. Many times people
58:00will say, oh, you are
58:01now have hypertension
58:03or you have,
58:05high glucose levels or metabolic
58:06syndrome. Let's now try and
58:07improve physical activity, diet, etcetera.
58:10Those are all now reactive.
58:11It's almost like the cat
58:12is out of the bag.
58:13Really think about proactive prevention.
58:16Kids who are young,
58:17populations who may have low
58:19burden of disease today but
58:20are at risk of higher
58:22burden of disease two, three
58:23decades from now, put in
58:24place protective measures, health protective
58:27measures for children today, put
58:29in place the structures and
58:30policies and behaviors for populations
58:32so that they can prevent
58:33that epidemiological
58:34transition
58:35from happening.
58:37I know I'm close to
58:37the end of time. A
58:39few touchy feely slides on
58:40just some lessons I've learned,
58:41during my time in global
58:42health because I see a
58:43lot of trainees here in
58:44the audience today.
58:46One thing I've learned is
58:47know your DNA. Figure out
58:49who you are, figure out
58:50what it is that you
58:51want to do and what
58:52you're good at, and follow
58:53that passion.
58:54So this was, these are
58:56pictures from,
58:57Newbury, United Kingdom. So when
58:59I was there at Oxford,
59:01there was the the plan
59:02by the government to build
59:03a highway through this forest
59:04in this area called Newbury.
59:06And there were a bunch
59:07of protests, a bunch of
59:08direct action.
59:10People were chaining themselves to
59:11the trees. They were living
59:12up in the trees in
59:13order to prevent them from
59:14being cut down.
59:15I didn't do any of
59:16that, like, really crazy stuff,
59:18but I was involved in
59:19the marches and and whatnot.
59:21But what I realized was
59:22that in the end, it
59:24this wasn't me. Like, I
59:25was so happy for and
59:27respectful of the guys who
59:28were doing all this, like,
59:29direct action and out in
59:30the streets and in the
59:31trees and whatever. But if
59:32I was gonna put my
59:33stamp on the world, I
59:34needed it to reflect who
59:35I was. I needed to
59:36know who my DNA what
59:38my DNA was. So really
59:39know your DNA,
59:40But recognize that the entire
59:42spectrum is necessary. And I
59:43here I have three pictures
59:44of three friends, Sandeep Kishore,
59:46Kirikayana,
59:47Sonak Pastakya,
59:49and here the idea of
59:50access of access to medications.
59:52You need, obviously, obviously, the
59:53folks who are gonna be
59:54involved in all of the
59:55international multilateral
59:56agencies to create
59:58agreements across the world in
60:00order for pharmaceutical agents to
01:00:01be distributed and marketized and
01:00:03monetized around the world.
01:00:05You need procurement bodies represented
01:00:07by NGOs, the public sector,
01:00:08third party negotiators, etcetera. And
01:00:10you need finally the pharmacist
01:00:11like Sonak Pastakia,
01:00:13like myself, the clinician who
01:00:14are actually gonna be able
01:00:15to give patients those
01:00:17medications at the end. But
01:00:18who am I as a
01:00:19doctor? What am I gonna
01:00:20be able to do without
01:00:21actually the pharma company actually
01:00:22producing those medications? So recognize
01:00:24that the entire spectrum
01:00:26is necessary.
01:00:28Get started, make mistakes, but
01:00:31self correct. So this is
01:00:32a picture of a friend
01:00:32of mine and colleague, Sunita
01:00:34Krishnan.
01:00:35We were both students at
01:00:36at the University of California
01:00:37at the same time. She
01:00:38was doing a PhD in
01:00:39epi when I was doing
01:00:40my medical school there.
01:00:41We started a women's health
01:00:42program in South India. We
01:00:44made a ton of mistakes.
01:00:45We were students. We were
01:00:46naive. We had really no
01:00:47idea what we were doing.
01:00:49But many of those lessons
01:00:50that we learned during that
01:00:51time continued to live with
01:00:52me and continued to impact
01:00:54the work that I do
01:00:55even to this day. And
01:00:56a mentor of mine said,
01:00:58actually, if you never get
01:00:59started, you're obviously never gonna
01:01:00help anybody. And if you're
01:01:02too afraid to make mistakes
01:01:03and you paralyze yourself, you
01:01:04also won't help as many
01:01:06people as you should. But
01:01:07if you make mistakes and
01:01:08you don't self correct, obviously,
01:01:09that's not ideal. So
01:01:11get started, don't be afraid
01:01:12to make mistakes, but then
01:01:14self correct.
01:01:16That same mentor, Joe Mamlin,
01:01:18gave me this phrase which
01:01:19I live by every day,
01:01:21which is to dream all
01:01:21night
01:01:22and work all day. And
01:01:24the idea is that if
01:01:25you dream without working,
01:01:27nothing will get done. But
01:01:28if you work without dreaming,
01:01:30the work won't be meaningful.
01:01:31So dream all night, but
01:01:33work all day. I add
01:01:34in there make a little
01:01:35time for play because it's
01:01:36obviously important to take care
01:01:37of yourself as well. But
01:01:38dream all night, work all
01:01:39day.
01:01:41Also, the journey is larger
01:01:43than you. That there's only
01:01:44a certain amount that we're
01:01:45gonna be able to sort
01:01:46of carry this baton, and
01:01:47we'll be passing that baton
01:01:49on to the next generation.
01:01:50So I'm happy to see
01:01:51the younger folks here. Pictured
01:01:52here are my two daughters,
01:01:53Leila and Asha. I'll be
01:01:55passing the baton on to
01:01:56them.
01:01:57You know, we are passing
01:01:58the baton onto you as
01:01:59we stand here in front
01:02:00of you today. But the
01:02:01idea is that you can
01:02:02only take it so far.
01:02:03The journey is larger than
01:02:04you. You will be passing
01:02:05that baton on as you
01:02:06go forward as well.
01:02:08And finally, in the end,
01:02:10everything will be okay. And
01:02:11if it's not okay, it's
01:02:13not yet the end. I'm
01:02:14gonna say that one more
01:02:15time, in the end everything
01:02:16will be okay. And if
01:02:18it's not okay, it's not
01:02:19yet the end. So in
01:02:20conclusion, cardiovascular disease and risk
01:02:22factors are a global problem.
01:02:24There are obviously huge treatment
01:02:26and prevention gaps, but it
01:02:27is possible, and I hope
01:02:28I've shown you today that
01:02:29it's possible to translate those
01:02:30challenges into opportunities,
01:02:32think about the broader system.
01:02:34And in my case, I've
01:02:36thought about climate change, air
01:02:37pollution,
01:02:39cardiovascular disease, social and structural
01:02:40determinants of health, and how
01:02:41to incorporate all of that
01:02:43into the work that's being
01:02:44done. I wish to obviously,
01:02:45this is only a partial
01:02:47list of many, many collaborators
01:02:48from around the world who
01:02:49I wish to thank,
01:02:50and I wish to thank
01:02:51you as well. Thank you
01:02:52so much.
01:03:01And, I'm sure there'd be
01:03:02some comments or questions.
01:03:05You know, I think, as
01:03:06I reflect, I think one
01:03:07thing that maybe is an
01:03:09undercurrent of what we've
01:03:12done is the impact of
01:03:13actually
01:03:14testing hypothesis.
01:03:16Now what we are looking
01:03:17at, like,
01:03:19a lot more that in
01:03:20this day of AI, how
01:03:22you can understand that we
01:03:24actually,
01:03:25broke innovating with new technologies.
01:03:28And we need to test
01:03:29those technologies to put them
01:03:31into practice. And I think,
01:03:33I think you can you
01:03:34know, this is really really
01:03:35remarkable work.
01:03:37I'll start to offer that.
01:03:39You've,
01:03:40even though you're
01:03:41you remind me of how
01:03:43old I am.
01:03:45Yeah.
01:03:46You you've done
01:03:47so much,
01:03:48in your career today. One
01:03:50of the things that maybe,
01:03:52is not right, I believe
01:03:54you've chaired the section
01:03:56for,
01:03:58the Fogarty sect the Fogarty,
01:04:01funding section,
01:04:03which is one of the
01:04:04any NIH,
01:04:06institutes,
01:04:07focused predominantly on
01:04:09global health and other things
01:04:11in the bank.
01:04:13Look, I'll get you political,
01:04:14but how do you,
01:04:17how do you see that
01:04:18moving forward in this era,
01:04:20this concept of reciprocal innovation
01:04:22that can't be highlighted enough.
01:04:25Do you how do you
01:04:26envision
01:04:27what recommendation do you
01:04:29give to the community
01:04:30that wants to do this
01:04:32kind of work
01:04:33to test solutions
01:04:35in
01:04:36in patient community globally.
01:04:38To get
01:04:39tested. How how would you
01:04:41recommend to see in this
01:04:43environment and living this for
01:04:45them? Yeah. Thank you. It's
01:04:46actually, obviously, a critically important
01:04:48question.
01:04:50But it reminds me actually
01:04:51of a phrase that, you
01:04:51know, the more things change,
01:04:53the more they stay the
01:04:54same. At some level,
01:04:56federally US federally funded global
01:04:58health work,
01:05:00has always been part of
01:05:02the US federal government's
01:05:04approach to global international diplomacy
01:05:06in general.
01:05:07That it has never been
01:05:09just sort of,
01:05:10an investment on its own.
01:05:11It's always been in the
01:05:12context of sort of global
01:05:13diplomacy
01:05:14and how is it that
01:05:15we sort of navigate ourselves,
01:05:17whether
01:05:18it's, like, power or soft
01:05:20power or hard power, etcetera,
01:05:21relative to the rest of
01:05:22the world. And so,
01:05:25there has been a paradigm
01:05:27that has evolved since, let's
01:05:28just say, World War two
01:05:29in terms of the sort
01:05:31of growth of global health
01:05:32and US federally funded,
01:05:34global health, whether it be
01:05:36in in implementation
01:05:37or whether it be research.
01:05:39But I believe it has
01:05:40always actually been in the
01:05:41context of, quote, unquote, America
01:05:42first. It has always been
01:05:44in the context of where
01:05:45is the United
01:05:47States relative to the rest
01:05:48of the world. We are,
01:05:49use we have traditionally been
01:05:51using, you know, whether it's
01:05:52diplomatic channels, whether it's global
01:05:54health, whether it's other,
01:05:56sort of, funding,
01:05:57decisions that have been made
01:05:59to think about soft power
01:06:00that accompanies hard power such
01:06:02as, let's say, military presence.
01:06:04That soft power has always
01:06:05had a goal with respect
01:06:06to, you know,
01:06:08economic,
01:06:09essentially,
01:06:10not empowerment, but sort of
01:06:11economic interests of of this
01:06:13country,
01:06:14security interests of this country.
01:06:17You know, and sort of
01:06:18thinking about, you know,
01:06:20even the same three questions
01:06:21that Marco Rubio put forth
01:06:22in January,
01:06:24every US dollar that gets
01:06:25spent abroad, how is it
01:06:27gonna make us, quote, unquote,
01:06:28more powerful? How is it
01:06:29gonna make us more prosperous?
01:06:30And how is it gonna
01:06:31make us safer? Those three
01:06:32questions, to be honest with
01:06:33you, I think are no
01:06:34different than they have been
01:06:35actually for the last fifty,
01:06:36sixty years. It's the way
01:06:38that they are manifesting today,
01:06:40the rapidity with which some
01:06:41of those changes are happening
01:06:43that obviously makes it feel
01:06:44like that cookie jar is
01:06:45being, like, sort of, like,
01:06:46shaken.
01:06:47That being said, those sort
01:06:49of fundamental questions, I don't
01:06:50think actually are that different.
01:06:52There will be a new
01:06:53system and a new equilibrium
01:06:55that sort of probably,
01:06:57sort of ultimately
01:06:59evolves, and we will have
01:07:00to navigate ourselves through that
01:07:01system just as we've been
01:07:02doing in the past. Very
01:07:04helpful. Got a message. Yeah.
01:07:06Any comments or questions? Anybody,
01:07:09brave enough to ask John
01:07:11first, I guess, but bring
01:07:13it to anyone else?
01:07:17Really? I might turn it
01:07:18on.
01:07:21That's really amazing and wonderful
01:07:23work. But I'm somewhat conflicted.
01:07:27About thirty years ago, I
01:07:28spent some time in Papua
01:07:29New Guinea working there.
01:07:31And, clearly, the
01:07:33the health budget is very,
01:07:35very limited in many of
01:07:36those countries.
01:07:37And so then if you
01:07:38develop a cardiovascular
01:07:39program,
01:07:40the money has to be
01:07:42transferred from another area such
01:07:43as infectious diseases.
01:07:45And so I wonder, are
01:07:46we sort of imposing our
01:07:48healthcare culture
01:07:49on another country which may
01:07:51not necessarily need it? Yeah.
01:07:53So, also a great question.
01:07:54And in a way, it's
01:07:55a little bit of a
01:07:56corollary to the question that
01:07:57even Eric started with, which
01:07:58is obviously if you look
01:07:59at development assistance for health
01:08:01in general globally,
01:08:02there has been actually a
01:08:03sort of a slow decline
01:08:05over the last decade. Obviously,
01:08:06that took a sort of
01:08:07very shortens, sorry, very sudden
01:08:09downturn in the context of
01:08:11the last six months. And,
01:08:12again, everyone is scrambling to
01:08:13figure out, well, how do
01:08:14we now, quote, unquote, fill
01:08:15that gap? How will countries
01:08:17like P and G, like
01:08:18Ghana, like Kenya, like India,
01:08:20fill that gap that was
01:08:21being filled before by development
01:08:24assistance for health?
01:08:26The there are two realities,
01:08:27I would say. One is
01:08:28that because the same question
01:08:29came up actually in the
01:08:30context even of that, medical
01:08:32school project I mentioned about
01:08:34women's health in South India.
01:08:36Everyone there not everyone there.
01:08:37Many people were asking us,
01:08:38well, you're taking these US
01:08:40based ideas of what women's
01:08:41health should be and dah
01:08:42dah dah dah dah and
01:08:43taking it to India. Like,
01:08:44is that what they really
01:08:45want? Actually, the reality was
01:08:47that the women there wanted
01:08:48the compassionate care that they
01:08:50were not otherwise receiving. And
01:08:51so this idea that
01:08:53people may have different patients
01:08:55are patients ultimately, and and
01:08:56there's sort of a universality
01:08:58to health, wellness, and illness
01:09:01that I think is important,
01:09:02that I think we all
01:09:03probably recognize
01:09:05that ill patients in other
01:09:07places have the same concerns
01:09:09as ill patients even here,
01:09:10whether it be New Haven
01:09:11or New York.
01:09:12And so
01:09:14while people may say, oh,
01:09:15you know what? You're crowding
01:09:16out investments from infectious diseases
01:09:18or whatever. The reality is
01:09:19that people are dying from
01:09:20strokes, dying from ischemic heart
01:09:22disease, getting disabled from strokes
01:09:24and ischemic heart disease, and
01:09:26they know that actually in
01:09:27places like P and G,
01:09:28Ghana, Kenya, South Africa, etcetera.
01:09:31And their countries also need
01:09:33to respond to that. They
01:09:34recognize it. And so in
01:09:35a way, I don't see
01:09:36that conflict necessarily in the
01:09:38way that you're describing, although
01:09:40I understand. That being said,
01:09:42it will require definitely more
01:09:44resources and more funding. And
01:09:45in the context of
01:09:48insufficient investment on the part
01:09:50of,
01:09:51many governments around the world
01:09:52in terms of their public
01:09:53sector health infrastructure, it will
01:09:55require a definite
01:09:57definite reformulation
01:09:58of how they invest in
01:09:59health.
01:10:00That conversation is already starting
01:10:01to happen, actually. So I
01:10:03look at Kenya. I look
01:10:04at South Africa. I look
01:10:05at Ghana.
01:10:06Governments themselves are saying, you
01:10:07know what? We need to
01:10:07think about a revenue base
01:10:09that will allow us to
01:10:10actually address noncommunicable diseases as
01:10:13well as infectious diseases. And,
01:10:15again, I believe that we're
01:10:16actually in this concept, in
01:10:18this sort of parallel vein
01:10:19of translating challenge into opportunity.
01:10:21We're obviously in a very
01:10:22challenging situation now. But I
01:10:24think in the context of
01:10:26that challenge, there's an element
01:10:27of opportunity that if we
01:10:29can take advantage of, actually
01:10:30can make the world a
01:10:31much, much better place over
01:10:32the next five to ten
01:10:33years. That's my hope.
01:10:35Maybe last. Ahmed,
01:10:36sorry. You're you you you
01:10:38raised your hand a second,
01:10:39so I'll have it. Bernardo
01:10:40did the last word.
01:10:43Excellent. No. First of all,
01:10:44I mean, excellent conference. Thank
01:10:46you very much for coming
01:10:47to New Haven.
01:10:49After all your work in
01:10:50Kenya and in Africa, are
01:10:52you guys, seeing, like, a
01:10:54reduction of the brain drain
01:10:55in the physicians?
01:10:57Are, now the Kenyan doctors
01:10:59staying more in Kenya?
01:11:00Yeah. So it's a it's
01:11:01a great question. I I
01:11:02can't say that I can
01:11:03answer that from a totally
01:11:05data driven perspective. However, from
01:11:07a sort of our microcosmic
01:11:09Yeah. Experience in Western Kenya,
01:11:11I can actually proudly say,
01:11:13and I think Eric can
01:11:14also proudly say that, actually,
01:11:15we've trained a cohort of
01:11:18cardiovascular
01:11:19specialists in Kenya who have
01:11:21actually remained in Western Kenya.
01:11:23And part of our work
01:11:24with AMPATH Kenya and now
01:11:26increasingly with AMPATH Ghana is
01:11:28to actually try and provide
01:11:29concrete career development opportunities
01:11:32for folks there in order
01:11:34to reduce the sort of
01:11:36demand side
01:11:37of the pull to, like,
01:11:39try and leave that place.
01:11:40And so previously,
01:11:41actually, you know, people in
01:11:42Western Kenya would say, you
01:11:43know, there's no opportunity for
01:11:44me here. Why should I
01:11:45stay? But, actually, as a
01:11:47result of the efforts that
01:11:48I was describing that doctor
01:11:49Velasquez also
01:11:50led co led,
01:11:53I think we've been able
01:11:54to create now these career
01:11:55advancement opportunities.
01:11:56People feel like, you know
01:11:57know what? I can actually
01:11:58stay here, raise my kids
01:11:59here, you know, whatever, have
01:12:01a life, and also have
01:12:02a professionally meaningful engagement.
01:12:04So I can say at
01:12:05a microcosmic level, I think
01:12:07there has been an impact.
01:12:08Whether that translates into sort
01:12:09of country level nationwide statistics,
01:12:11I can't actually I don't
01:12:13have the data to be
01:12:14able to confirm. Yeah. That's
01:12:15a phenomenal question. I think,
01:12:18I would just give you
01:12:19one little you know, we
01:12:20lost our
01:12:22chief echo tech
01:12:24to Canada. Mhmm. We brought
01:12:25him you know, sort of
01:12:26the brain drain in the
01:12:26opposite direction sometimes,
01:12:28because you lee you you,
01:12:30integrate,
01:12:31opportunities,
01:12:33and, and and people
01:12:35build their lives
01:12:36and choose to build in
01:12:38the places where you've started
01:12:39working. So it's it's actually
01:12:40been a very interesting, journey,
01:12:42but it it's a great
01:12:43question. It probably requires study,
01:12:44frankly, in some meaningful way.
01:12:46So thanks, everyone. It's a
01:12:47great talk, and Thank you
01:12:49so much.
01:12:51Thank
01:13:02you.