A Peds-Eye View into the World

Rx: stories

If there’s one thing I’m excited to take away from my experience in North Dakota, it’s the power of the stories the Mandan-Hidatsa-Arikara (MHA) peoples shared with me. They do not feel like mine to tell, as I would want to do so appropriately, and accurately, but here is one of the stories a tribe member shared with me about Lodge-boy and Spring-boy:

https://web.archive.org/web/20140505145412/http://faculty.humanities.uci.edu/tcthorne/Socec15/lodgeboyandspringboy.htm

We were sitting around a table in the clinic, as he related in his animated voice and vivid gestures this tale of a broken family, betrayal, prejudice, but also rehabilitation, differences as strength, sacrifice, value in all kinds of community members, the importance of family… Sprinkled throughout were themes of magic, creativity, respecting and valuing nature and balance. This one story was so action-packed, and bursting with important messages – it embodies elements of trauma-informed care, and it’s from centuries ago! It reflects the core values and traditions of the MHA people, which our storyteller felt had been somewhat lost.

As we discussed our thoughts and reactions of the story with him, we realized there were parallels between these topics and the “modern day” issues plaguing the community – adverse childhood events like domestic violence, separated caregivers, family members affected by alcohol use disorder/illicit substance use, family members who have committed suicide or with severe mental illness, family members who have been incarcerated. But this legend also taught some healthy lessons about how to address these kinds of problems. Before us, we saw a heritage of wisdom regarding resilience. With all the efforts to erase the MHA communities, storytelling seemed to be a good way to revive it.

From a medical point of view, like the biopsychosocial model, we know the health and status of a community plays a role in individual health. We also know that the number of adverse childhood events a person experiences has a “dose” relationship to health challenges.

“Individuals with ACE sores of 4 or more were 12 times more likely to have attempted suicide, 7 times more likely to be alcoholic, and 10 times more likely to have injected street drugs. People with ACE scores of 6 and higher have an almost 20‐year shortening of lifespan.” -Pine Tree Institute

One way to address ACEs is to promote resilience, the ability to “bounce back” from difficulties. Resilience may come from a combination of traits like determination, toughness, optimism, faith, positivity and hope. The more you exercise it, the stronger it becomes. We believe that storytelling with these traditional tales can nurture these characteristics, promote closer relationships with caring adults, provide parenting skills, provide a sense of purpose and identity, allow for social and community connection, show that valuing health and supporting each other is important and beneficial.

We have been brainstorming community storytelling events to engage the elders/adults with kids and to revitalize pride in the wealth of cultural strengths these stories communicate. I forgot to mention, even in the act of storytelling, it is tradition to offer tribute to the teller to thank them for their actions and because paying a price apparently helps the receiver remember it more; so part of the kids’ experiences will be to create something together to offer to the storyteller that can be made a display of community. This is a health initiative we hope to help facilitate the revival of… let us know if you have any ideas!

Dam consequences.

Hearing that tampering with the environment devastated a local community may not surprise you. On a “smaller scale,” we encounter the impact of the environment on our patients’ health everyday, perhaps even our own health, whether it be asthma, diabetes, etc. Still, I’d like to share with you a little about one of the more recent, overlooked insults to the Mandan-Hidatsa-Arikara (MHA) Nation/Three Affiliated Tribes of the Fort Berthold Indian Reservation: the circumstances of the Garrison Dam. Even if the overarching theme may seem all too familiar, its details seem to be lesser known, and by no means are they any less significant, especially to the people of New Town, North Dakota. Branches and branches of issues have stemmed from this project. And as eloquently articulated by our co-resident, Dr. Joe Burns in his recently published article on “Land Rights and Health Outcomes in American Indian/Alaskan Native Children,” “relationships to land are closely tied to culture, health, and wellbeing for Indigenous peoples, and because settler colonialism ultimately eliminated self-determination and access to resources, [American Indian] people [have been] predisposed to experience traumas and health disparities.

In 1947, the U.S. Army Corps of Engineers took on a 6-year project to construct a dam in order to control flooding and to develop hydroelectric power along the Missouri River in central North Dakota. This would take up 152,360 acres.₁Placing a dam created an upstream reservoir, which the U.S. government named Lake Sakakawea.₂ Perhaps the most astonishing figure was the loss of 94% of their agricultural land from flooding by the reservoir. Not to mention the deluge lead to the destruction of the towns of Sanish, Elbowoods, Lucky Mound, Shell Creek, Nishu, Charging Eagle, Beaver Creek, Red Butte, Independence, and Van Hook.₃ The banks of the Missouri River in this region have been the home to the MHA natives for thousands of years. It defined their cultural practices: their relationships, the food they ate, their ceremonies, and permeated their stories and spiritual life. They were farmers whose earth lodge villages also served as rich trading centers, attracting both native nomadic tribes and foreign European travelers. Over the centuries for various reasons, whether it be smallpox or boarding schools, their way of life has already been chipped away. To make matters worse, the final settlement legislation denied the tribes the right to use the reservoir shoreline for grazing, hunting, fishing, irrigation development, etc. for cultural purposes. It also denied them the royalty rights on all subsurfaces. The residents were relocated to “New Town.” The tribes were ultimately remunerated $7.5 million, but they had little actual say in the matter as it was confiscated under eminent domain, in the context of the 1935 Rural Electrification Act, one of the New Deal proposals from the Great Depression.

Eminent domain is obviously controversial – is there “just compensation” in this context? And where is the data to compare the benefits of this dam, from the cons? At the time of inception, it would have created the second-largest reservoir in the world to collect water for irrigation and regional water needs, supplied jobs and electricity, but not enough effort or attention seems to be paid to measure the biopsychosocial harm to victims of the project. One of the government websites about the dam promotes it without so much a word of its negative impact: “The U.S. Army Corps of Engineers oversees management of the public lands and waters of Lake Sakakawea which provide a variety of benefits to the public which include: recreation, fish and wildlife, flood damage reduction, hydropower production, irrigation, municipal and industrial water intakes, water quality, and navigation.” As healthcare workers, we learn to recognize that this kind of trauma to the community affects its individuals’ mental hand physical health, and that the effects of this trauma can be intergenerational. Altogether they ripple through the healthcare system as well, creating more problems than there are resources. One of the healthcare workers in the community told me there was no accessible public data regarding the prevalence of mental health issues including suicides; but, he said, nearly everyone he knows has known someone who has either attempted or succeeded in committing suicide. The need for mental health providers is glaring, but he wishes he had the data to underline it.

If you visit the Interpretive Center in town, a cultural museum of sorts, you can listen to recordings of some of the displaced persons recalling their lives before the dam was constructed, and you will see on the plaques next to them note they are now living in bigger cities like Bismark, or having moved to South Dakota. The relocation fragmented the community and the stories of crossing the river or farming, are now but scenes to imagine of the past. And if you speak with some of the locals, you will also learn that some feel that losing their farming way of life has definitely impacted the food they eat and the work they do. Unfortunately, all this is not unique to MHA nation. The Indian Relocation Act (1956) forced Native Americans into urban areas, severing connections of many indigenous people to their heritage. This often correlates to subsequent consumption of low-cost processed foods whether by government aid or relocation to food “deserts,” combined with other historical trauma and adverse childhood events, placing individuals at risk to develop obesity and diabetes, among others — diseases already noted to be too prevalent among Native American youth.

If we agree that the environment (natural environment, land rights) is a significant determinant of health in such communities because it can be protective and a source of healing, then we know that this dam plays a role in the decline in health of the MHA nation, and there is an inherited a duty to at least acknowledge and then to work towards healing those harms. And these kinds of issues will continue to compound if we let them: new struggles with land rights and environmental transformation come in the form of the pipelines and the concerns regarding the effect of oil drilling on air and water quality.

Endnotes, other thoughts:

Unclear to me whether this trimmed the 988,000-acre reservation or the area was determined to be that size thereafter. Of the 988,000 acres of that reservation, only 457,837 acres are owned by the Native Americans. The rest is designated alternatively, for example, as wildlife refuges, etc.
This turns out to be rather ironic on several levels because these lands were owned by the Three Affiliated Tribes who have inhabited these lands thousands of years before colonizers arrived and did not choose this name. Furthermore, the name is perhaps arguably more significant to colonial American history because she is remembered as a guide of Lewis and Clark. They did use the more “accurate” spelling of her name, as she may have been more commonly known as Sacagewea/Sacajawea.
If you visit the town library, on a board in one of the side rooms, you can view pictures of the old towns, and a map to envision what the land looked like previously. It’s a small quaint library, and a quiet display, but one not to be missed…

References:
1. Burns J, Angelino AC, Lewis K, Gotcsik ME, Bell RA, Bell J, Empey A. Land Rights and Health Outcomes in American Indian/Alaska Native Children. Pediatrics. 2021 Nov;148(5):e2020041350. doi: 10.1542/peds.2020-041350. Epub 2021 Oct 27. PMID: 34706902.
2. https://www.nwo.usace.army.mil/Missions/Dam-and-Lake-Projects/Missouri-River-Dams/Garrison/
3. https://en.wikipedia.org/wiki/Garrison_Dam
4. https://www.mhanation.com/interpretive-center

Sticks and Stones

Whether a pediatric clinic is in the middle of New York City or in the middle of oil fields in North Dakota, many of the same concerns and illnesses walk through the door. There are runny noses, vaccinations, sport physicals, developmental concerns, etc. abound! Unfortunately, child abuse and neglect is also prevalant across the country.

What started as another visit for a runny nose turned into my most memorable patient visit of the month. As the patient was running down the aisle it was impossible not to notice their significant genu varum.

I entered the exam room to get the story. The patient’s aunt had brought him in because he had a runny nose and cough for the last several days. She was concerned about COVID-19. His covid test was negative. I could finally ask what I had wanted to know more about the entire visit, how long had his legs been shaped like that?

His aunt explained that they had looked that way as long as she could remember. When the patient was several months old, his mother had passed away. He then went to live with his grandparents. The patient had been taken out of his grandparent’s custody and placed in his aunt’s custody several times. The aunt explained to me there was concern about the safety of his grandparents house as well as concern for drug use by his grandparents. Each time, the grandparents had been able to get approval to have their grandchild back. She told me it was common for the patient’s grandparents to leave the patient in one of those standing activity centers for most of the day, and maybe that’s why his legs were bow legged. That’s what she had always thought.

Luckily, the clinic had x-ray. So we got lower limb x-rays and drew some labs. The labs hadn’t resulted by the time I left North Dakota. The x-rays didn’t have any gross fractures that we could see at the time they were shot, but the official radiology read takes several days to come back. The read listed a plethora of differentials from the radiologist, some including vitamin deficiencies and lead poisoning. We referred this patient to the nearest pediatric orthopedist, which is 2 hours away from New Town. The current pediatric provider at the clinic felt however, that in his case he would ultimately be referred to Mayo Clinic in Minnesota, an 8+ hour drive, for his subspecialty care.

The scariest part of this patient encounter was that in several weeks there would be no pediatric provider in the clinic to follow-up on him. It is very hard for the clinic in New Town to find providers willing to live and work in the area, especially for a long period of time. The next closest provider dedicated to pediatrics is an hour away. My co-resident and I often commented how strange it felt to be an hour away from any major medical center, especially coming from New York City, where this is a hospital practically every other block. Throughout the rotation, I gained a better understanding of the implications of practicing in a rural area. I won’t forget that patient’s smiling face and cute curly hair. I hope he finds the specialty care he needs, and a nurturing home to grow up in.

Growing Up

In the summer of 2009, I had the privilege to travel to Pine Ridge Indian Reservation with a service group through my church. Prior to this experience, I had lived a very sheltered life. I grew up in a mostly white, middle class, suburb of the Minneapolis – St. Paul area. My parents were married, both working full time jobs they enjoyed. I got to participate in competition dance and spend weekends at the lake. My closest brush with poverty was encountering the occasional person experiencing homelessness walking into Saturday morning ballet class in downtown Minneapolis. I was beyond blessed, but I didn’t know anything else, so I did not realize just how incredibly lucky I was.

On this trip, we spent one week helping supervise the grade school summer camp at the local school and another week painting houses on the reservation. The most memorable moment came when I was painting a house of a single mother with several small children. The mother was so welcoming. After a few days, she invited me in to use her restroom instead of walking to the community center. As I walked in her front door, she continually apologized for the appearance of her home. I have a lasting mental image of what her bathroom looked like because it broke my heart. There was black mold extending down from the sink across the floor, as well as at joining between the tub and the floor. I teared up in that bathroom, thinking about how this was home for those beautiful children and generous mother.

I think about that day often. When I was growing up, living situations like that always seemed to be so far away. Across an ocean, in a country with an unstable government and plagued by war. It was never in my own backyard, and yet, only a few hours drive from my hometown, here it was.

When the opportunity came up to go to New Town with CCMC, I knew I had to go. When we first got to the reservation, I was surprised. There were beautiful homes and clean streets. I am sure that existed at Pine Ridge, but the images I remembered were the homes that appeared to be falling apart and walking past syringes on the side of the road near the school. It wasn’t until we started talking to community members that we learned about the ways this population of people were suffering. We learned about the prevalence of fentanyl, alcoholism and mental illness on the reservation, all further exacerbated by the pandemic.

One case-worker showed us books on statistics they were gathering about the community in order to better address the needs. The fact that stood out to me the most when I read it was that the average life expectancy for a male on the reservation was 57 years old. Earlier that year, I had lost my Dad at the age of 57. At his funeral, everyone kept saying, “he was so young.” They were right, he was young. But on the reservation, that was the average. Many men only lived to 57. It was what they could expect. I knew what it was like to lose a loved one at that age. It meant that many of the members of this community were mourning the years of memories that could have been, just like I was. I asked the case-worker if he knew why the life expectancy was so short. He responded that the many overdoses and suicides by firearms on the reservation were major contributors. I found myself tearing up and broken hearted again. My dad passed away from a rare aggressive cancer, these men were taken too soon by preventable illnesses that were the product of their environment.

Again, this was happening in my own backyard. A several hours drive from where I grew up. I cannot ignore it.

In It For The Long Haul

What happens when COVID becomes a nightmare with no end in sight? Most patients with symptomatic COVID clinically improve within several weeks of infection. But for those with post-COVID conditions, symptoms last longer. The Centers for Disease Control and Prevention (CDC) defines post-COVID conditions as new or ongoing symptoms occurring at least four weeks after initial infection. The World Health Organization (WHO) defines post-COVID conditions as at least one symptom that typically starts within three months of infection and lasts at least two months. Other names for this problem include long COVID, long-haul COVID, and chronic COVID. Anyone who has had COVID, regardless of age or clinical presentation at the time of initial diagnosis, can develop post-COVID conditions. This includes children who previously had multi-system inflammatory syndrome. The cause is unknown. It has been hypothesized that symptoms are due to disruptive, persistent viral fragments or caused by a post-infection autoimmune response. It is also possible that multiple mechanisms contribute to the development of symptoms. The number of U.S. cases is estimated to reach up to 10 million. Research to better understand the prevalence and pathophysiology of post-COVID conditions is ongoing. For example, earlier this year, the National Institutes of Health announced a plan to spend $1.15 billion on post-COVID conditions research.

The most common symptoms are fatigue, headache, insomnia, difficulty concentrating, myalgia, arthralgia, and cough. Other possible symptoms include difficulty breathing, post-exertional malaise, chest pain, abdominal pain, headache, palpitations, paresthesias, diarrhea, fever, lightheadedness, rash, mood changes, changes in smell or taste, and menstrual cycle changes. Symptoms may change over time. CDC recommends the same prevention strategies for post-COVID conditions as it does for COVID itself: vaccination, masks, social distancing, and handwashing. The effect of COVID vaccination is unknown, although some people have reported improvement in symptoms after getting the first dose.

Post-COVID conditions tend to affect normal functioning. Examples include brain fog that impairs cognitive activity, shortness of breath that limits respiratory function, and fatigue that prevents performance of everyday tasks. If post-COVID conditions substantially limit major life activity, then the patient is considered to have a disability according to the Americans with Disabilities Act. The patient would be entitled to the same protections from discrimination as anyone else with a disability, and accommodations might need to be made to support the patient’s daily functioning. For example, a child with post-COVID conditions might need extra time to complete assignments at school due to cognitive symptoms.

WHO COVID treatment guidelines recommend access to follow-up care for possible post-COVID conditions. One option for follow-up care is post-COVID care clinics, which provide multidisciplinary care to people with post-COVID conditions. Specialties involved include pulmonology, cardiology, neurology, and more. Post-COVID care clinics have been set up in all five NYC boroughs. Options in Queens include: the COVID-19 Community Health Center at NYC Health + Hospitals/Gotham Health, Roosevelt, in Jackson Heights; the post-COVID center at the Jamaica Hospital Medical Center/Flushing Hospital Medical Center site MediSys-Hollis Tudors in St. Albans; and the Northwell Health COVID Ambulatory Resource Support (CARES) program, which has multiple physical locations and virtual options.

Sources

The Price of Connection

October 4, 2021, a day that will live in infamy – at least for those of us that use social media. That day saw the longest recorded outage in the history of Facebook and its associated apps, Instagram and WhatsApp. I spent much of that afternoon refreshing my various apps waiting for everything to come back online, especially since I was in North Dakota working on a Native American reservation at the time and those apps were some of my only connections to friends and family back home (and to all of the cute dog accounts I follow). But as I aimlessly stared at my unchanging Instagram feed, I was also reminded of the news that had been coming out about the company. In mid-September the Wall Street Journal released The Facebook Files, a compendium of articles detailing the harms caused by the company. The details about the detrimental effects that Instagram has on the mental, and sometimes physical, health of teenage girls hit me particularly hard as a pediatrician who takes care of teenagers and a former teenage girl myself – and as someone who had just witnessed the effect of social media on a teenage girl and her school community.

About one week earlier, my co-resident and I sat in on an assembly for seventh and eighth graders at the local middle school. One of the students had recently been subjected to severe cyberbullying – inappropriate photographs of this student had been circulating around the school and mocked online and as a result, she had become suicidal. The school brought in a local police officer to review laws related to cyberbullying and child pornography, and members of the staff discussed the effect that this situation had on them personally and on the school community as a whole. The whole experience was eye-opening. To think of a young girl being tormented to the point where she considered taking her own was horrifying and heartbreaking. But unfortunately in the age of social media, cyberbullying and its consequences are all too common even among pre-teens and teens. One in five American teens report being the victim of cyberbullying and this rate increased during the COVID-19 pandemic as more and more teens were spending more and more time with their electronic devices. And unfortunately, this can occur in any community – including ones with limited mental health resources for adolescents like this community in North Dakota. Thankfully this student was able to get the help she needed, but unfortunately, there are too many who do not – like the teenagers who would come into the ED at my home institution after an attempt at taking their own lives.

This experience was a reminder of the universality of mental health crises and the ever-evolving role that bullying plays in precipitating these crises among teenagers. When thinking about global health, we often think about the differences between health in different places and different communities. But struggles with depression, bullying, anxiety, imposter syndrome, and suicidality exist everywhere. While this incident took place among a native population in the northern United States, it could have just as easily happened in a wealthy, cosmopolitan community in Paris or a poverty-stricken, rural community outside of New Delhi. As the world grows more connected through social media, we must also become more mindful of the effects these resources have on our health and the health of those around us.

For those interested in reading more about the effects of Facebook on mental health, politics, and more, the Facebook Files can be found at https://www.wsj.com/articles/the-facebook-files-11631713039.

Pollution in the Pandemic

Imagine the typical COVID-positive patient admitted to the floor. Every day, an intern pre-rounds on the patient, then an entire team rounds, then nurses and other staff come in and out of the room repeatedly. Each time one of these people enters the room, a gown, mask, pair of gloves, and disinfecting wipe will be used and then thrown out. This substantial use of personal protective equipment (PPE) has been happening on a global scale since the beginning of the COVID pandemic. Most PPE, as well as components of COVID tests and vaccines, are single-use plastics (SUPs). SUPs are used once and then discarded. Non-medical examples of SUPs include hand sanitizer bottles, disposable food containers, and other products that have become more popular during the pandemic. A recent study estimates that 1.6 million tons per day of plastic waste have been created globally since the beginning of the pandemic. This estimate includes 3.4 billion face masks/shields per day, 219 million of them from the U.S.

The pandemic-related increase in SUPs will worsen waste and pollution around the world. Think about happens to a used face mask. The best possible outcome is that it gets thrown out as medical waste or regular trash. It should not be recycled in most areas because its components cannot be separated properly for the recycling process, and it can cause issues by getting stuck in recycling machines. From the garbage, it will go to a landfill. This will worsen the issues of air pollution and medical waste that existed before the pandemic. Healthcare facilities in the U.S. were already dumping 6,600 metric tons of medical waste per year into landfills, which emit harmful greenhouse gas emissions into the air. This contribution will only grow as the pandemic continues. If the mask is thrown on the ground instead, then it will become litter in a natural environment. One of these environments is the ocean, where it has been estimated that 1.56 billion masks ended up in 2020. The mask might kill an animal that tries to eat it or gets tangled in it. It could alternatively break down into microfibers over time. Microfibers are a type of microplastic, defined as a plastic piece with <5 mm diameter. Microfibers from the mask will remain in the environment for decades at least. It has been estimated that 173,000 microfibers can be released into the ocean from just one mask. There is concern among scientists about microfibers because they can contain toxic chemicals, have unknown effects on humans, and can harm aquatic animals that eat them. These are the realities of what happens to masks and similar SUPs when they are thrown out. We forget about them immediately, but they tend to have long lives ahead of them.

Ways to limit further consequences of COVID-related waste include avoiding unnecessary use of PPE by minimizing the number of visits into/people entering contact precaution rooms, properly disposing of sealed PPE as garbage or medical waste, and creating more reusable products for the future. Although PPE and SUPs will continue to be used in large amounts during the pandemic, it will be important to minimize their effects on the environment.

Sources

Telehealth Takeover

With the COVID-19 pandemic we saw a tremendous increase in the use of telehealth/telemedicine. Telehealth is simply defined as the delivery of health care services at a distance through the use of technology. The number of telehealth visits increased by 50% in the first quarter of 2020 compared to the first quarter of 2019, according to the CDC. One in four Americans over age 50 said they had a virtual health care visit during the first three months of the pandemic. Telehealth is not a new concept, beginning with doctor’s using home telephones in the 1800s to reduce office visit. In the early 1900s radios were used for doctors to make diagnosis. While house call physicians have fallen out of popularity over the years, telemedicine takes modern approach on this concept. With technology being a part of our everyday life and increasingly easier access to technology, telehealth has become more accessible. Like most things in life there is advantages and disadvantages to telehealth:

Advantages of telehealth:

-Convenience: Allows patients to avoid the cost of transportation, taking time off from work, and unnecessary emergency department visits

-Increases access to care for those living in rural areas who may not have access to local clinics or doctors

-Less exposure: Decreases exposure to sick individuals which is especially beneficial during a pandemic

-Increased access to specialists who are located far from patients

-Helps patient be more involved in their care through apps that can help them follow along with their health

Disadvantages of telehealth:

-Barrier to access for those who have limited access to internet or smart devices

-Difficulty performing a good physical exam which can lead to misdiagnosis and medical errors

-Loss of building provider-patient connections which is sometimes accomplished through physical presence

-Privacy concerns if not using a secure internet connection

-Some insurance companies do not cover telehealth visits and patients might have to pay out of pocket

According to the COVID-19 Healthcare Coalition, which surveyed physicians about their telehealth experience during the pandemic, more than 60% of physicians reported that telehealth is easy to use within their practice across urban, suburban, and rural locations. In the same study, more than 50% of physicians reported improved satisfaction with their work. While there is certain specialties that will still need to see their patients in person, such as surgical specialties, using telemedicine for certain doctor visits can prevent healthcare fatigue for patients having to coordinate multiple visits by allowing you to easily do these visits in the comfort of your home. The use of telemedicine is here to stay so as physicians we must learn to adapt to changing tectological advancements and continue to strive to give the highest quality of care to our patients.

References:

https://c19hcc.org/telehealth/physician-survey-analysis/

https://www.cdc.gov/mmwr/volumes/69/wr/mm6943a3.htm

https://www.ncbi.nlm.nih.gov/books/NBK207141/

Inspirational Physicians in Public Health

For some physicians, a career in public health is inspired from what they experience in their own fields. Here are some inspirational figures that have had fascinating impacts in the field of public health.

Dr. Virginia Apgar

Although many know her last name as a standard in pediatric care, Dr. Apgar was trained as a surgeon and anesthesiologist at Columbia University. She developed the Apgar score to standardized the effect of anesthesia on babies given to mothers during childbirth. After her work in anesthesia and developing the score, she earned her MPH from Johns Hopkins and then served as Director of the National Foundation for Infantile Paralysis (predecesor of March of Dimes) until her passing.

Dr. Jocelyn Elders

Dr. Elders was the first African American Surgeon General of the United States. She grew up in a poor family in Arkansas and was unable to see a doctor until 16 years of age. She completed her medical training at the University of Arkansas Medical School. She became the first board certified pediatric endocrinologist. After some time, she went to work in the Arkansas Department of Health improving child vaccination rate and expanding prenatal care. She served as Surgeon General and after her term worked at Arkansas Children’s Hospital.

Dr. Susan Desmond Hellman

She began her medical training at University of Nevada and followed with residency and fellowship in oncology at UCSF. She became a biostatistics and epidemiology professor at UCSF working on Kaposi’s sarcoma. She began working for Genentech and eventually became Chief Medical Officer working on the creation of Taxol, Avastin, and Herceptin during her tenure. She was the first woman to hold the position of Chancellor of UCSF. Eventually she became CEO of the Bill and Melinda Gates Foundation for 5 years until she joined President Bidens’s Council of Advisors on Science and Technology.

Dr. Ann Mckee

Dr. McKee’s completed her medical degree at Case Western School of Medicine with a residency in neurology and neuropathology at Cleveland General and Massachusetts General respectively. Her work in chronic traumatic encephalopathy and Alzheimer’s led to the creation of McKee criteria to diagnose CTE. She now directs the largest brain bank including the directory for the Framingham Heart Study.

Dr. Nadine Burke Harris

Dr. Burke Harris started her medical education at the University of California, Davis. She completed her pediatrics residency at Lucille Packard Children’s Hospital and went on to found a clinic in Bayview Hunter’s Point, one of the most underserved areas in San Francisco. She completed her MPH from Harvard T. H. Chan School of Public Health. Using data from the CDC and Kaiser Permanente, her work in Adverse Childhood Events has shifted the discussion about traumatic events in childhood and their impact on health. She is currently serving as the first California Surgeon General.

Dr. Mona Hanna-Attisha

Dr. Hanna-Attisha graduated with a Masters in Public Health from the University of Michigan and then completed her medical school training at the same institution. She finished pediatrics training at Children’s Hospital of Michigan in Detroit. Her statistical evidence and persistence brought to light the Flint water crisis and its impacts on the population. The government initially tried to discredit her evidence but her work with the community brought national attention to the crisis. Her advocacy work continues as the founder and Director of the Pediatric Public Health Initiative.

Dr. Leana Wen

Dr. Wen started her medical education at the Washington University School of Medicine and studied health policy at Oxford University as a Rhodes Scholar. She completed her emergency medicine training at Brigham & Woman’s Hospital and Massachusetts General Hospital. She later led the Baltimore Department of Health as Commissioner of Health battling the opioid epidemic. She now serves as the president of Planned Parenthood providing medical services and advocating for women’s health across the nation.

These are just some examples of many physicians who have pivoted their careers and make a huge difference in the field of public health. Many of them have written books about their journeys and what inspired them to pursue their passions and advocate for the health of the vulnerable. Although we think of medical education as a very linear trajectory, it is important to remember there are many ways to help the populations we serve. We can utilize the skills we pick up in medical school, residency and even as an attending to approach issues in public health from a different perspective and truly shift the conversation about issues we are passionate about.

References

https://onlinepublichealth.gwu.edu/resources/medical-doctors-turned-public-health-professionals/

https://www.aamc.org/news-insights/celebrating-10-women-medical-pioneers

https://en.wikipedia.org/wiki/Sue_Desmond-Hellmann

Important Women in Public Health

Ann McKee, MD

https://time.com/collection/health-care-50/5425016/ann-mckee/

Office of the California Surgeon General

https://monahannaattisha.com/about

https://publichealth.gwu.edu/departments/health-policy-and-management/leana-wen-md-msc_faaem

https://time.com/collection/health-care-50/5425000/leana-wen-2/

A Pandemic Within a Pandemic

What happens when the one place you’re supposed to feel the safest, your home, actually turns into the opposite. One of the forgotten issues of the pandemic has been the increase in intimate partner violence (IPV). IPV is defined as physical, emotional, psychological, or economic abuse and stalking or sexual harm by a current or former partner or spouse. People of all races, cultures, genders, sexual orientations, socioeconomic classes, and religions experience IPV. When the pandemic first started, everyone was advised to work from home, social distance, and not leave their houses unless needed. While this might have helped slow the spread of COVID-19, it helped create an ideal condition for intimate partner violence. The social isolation of quarantining has left individuals spending more time at home with their aggressors. While we have all been so busy adapting to the new way of life many have been fighting for their lives in their own homes.

According to the CDC, 25% of women and 10% of men experience some form of intimate partner violence in their lifetime. According to U.S. crime reports, approximately 16% of all homicide victims are killed by an intimate partner. The United Nations Population Fund estimates a 20% increase in IPV globally due to quarantines and lock downs. Some reason for this increase may be increased loss of jobs, lack of ability to pay for housing and food, and/or increased amount of time spent indoors which may exacerbate social and livelihood stresses. Increase social isolation has created an environment where victims cannot separate themselves from the aggressors. With many shelters and IPV survivor programs closed or also locked down, individuals fleeing abusive partners have no place to go.

So what can we do to combat this issue? First we must know that, most people who experience IPV do not seek help. Medical professionals have an opportunity to identify these patients in health care settings through screenings and to provide counseling and connect people with social services. We can urge the government to provide necessary assistances such as unemployment, food, rent or mortgage assistances, to help with these stressors that have been found to increase IPV during this pandemic. Also providing public awareness on resources to the broader community, community members, trusted friends, neighbors, and family members may be better able to connect those affected by IPV with resources, such as shelters, treatment intervention program, and therapeutic professionals (e.g., social workers, psychologists, etc.). We must also remember that “COVID doesn’t make an abuser, but it can exacerbate it”. Below is a table of ways to prevent abuse before it starts.