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On Oct. 13, the virtual Levy Lecture Series welcomed Dr. Kenneth Schaefle to talk about his experiences treating patients and teaching medical students while working at clinic in Kisoro, Uganda, the unofficial “campus” of the Global Health Center at Albert Einstein College of Medicine, where he is an Assistant Professor.
No doubt there was some hometown interest in Dr. Schaefle’s presentation: He grew up in Evanston; he graduated from Evanston Township High School in 1986; and his father still lives here.
Dr. Schaefle said he is profoundly grateful to Evanston and the community organizations his parents exposed him to, such as the McGaw YMCA and scouting, but most of all he is grateful to have attended such a fine high school – and grateful for the people paying the high property taxes that support ETHS.
Dr. Schaefle is an unabashedly enthusiastic alumnus, saying, “Whatever you were into, people got to know themselves at Evanston High School. And you were able to try things on an amateur level that later you might do professionally.” He acknowledges ETHS for nurturing much of his drive and intellectual curiosity, especially as a student undertaking the rigorous, three-year Chemistry-Physics program. Problem-solving and teamwork were only two of the many lessons he learned there, he said.
The presentation to the Levy Lecture audience at times seemed like a conversation between old friends. Dr. Schaefle is a natural teacher, a good public speaker and very receptive to questions. In fewer than30 minutes, he gave a solid introduction to what global health is and how it differs from the type of medicine most know. He said it was crucial for the Levy audience to understand how global factors contributed to the viability of Kisoro’s residents and how he taught the medical students. Talking about the clinic would be meaningless without the global context.
The most salient difference between health care in the developing world (Kisoro for this discussion) and health care in a nation like the United States is the starkness of the contrast. Kisoro faces almost a complete lack of infrastructure – few roads, erratic electricity, sparce availability of clean drinking water, low literacy rates, and sporadic plumbing. These factors contribute to poor access to traditional medical care. Nor are there diagnostic machines like CT scans or MRIs.
Surgery is a rarely used option. Infectious diseases like tuberculosis are prevalent, and there is widespread exposure to animals and their waste and to parasites. Many suffer from poor nutrition although food is plentiful from widespread farming. Cumulatively, many illnesses, easily treatable in the U.S., are the cause of premature death in Uganda.
Dr. Schaefle said, “Global health is what our grandparents had,” when much of the population in the United States supported an agriculturally-heavy economy. As more people moved away from farming and into urban areas, overall health care, and the health of the population, began to improve. Sadly, this pattern of increasing infrastructure to improve the health of the population has not taken place in sub-Saharan Africa.
One example of how infrastructure contributes to overall health may be seen in the way the city of New York eliminated cholera in the second half of the 19th century. The city, he said, “built its way out of it.” Without any knowledge of bacteria, and years before antibiotics were developed, the city leaders were savvy enough to realize that the combination of drinking water, farm animals like pigs, and animal waste created a lethal disease that killed thousands. In response, the city government committed to building the Croton Aqueduct, a secure water distribution system (1842); it banned swine from being housed near residential areas (1849); and it created 70 miles of underground sewers (1850-1855) to get rid of human waste. Cholera epidemics ended. Clean drinking water away from farm animals combined with sanitary waste disposal saved the lives of the city’s residents.
Having set up the general description of life in Kisoro, Dr. Schaefle got to the heart of his presentation, explaining four important aspects of global health: epidemiologic transition, population and gender roles, poverty, and lack of healthcare infrastructure.
Epidemiologic transition describes the juxtaposition between development and infectious disease. As a society increases its infrastructure and develops better standards of living, the risk of dying from infectious disease decreases while “lifestyle diseases” such as diabetes, obesity, and hypertension increase. Conversely, people in poorly developed societies like Uganda face tremendous risks and increased mortality from infectious diseases, sanitation diseases, parasites, and bacterial infections, but negligible risks from lifestyle diseases.
Populations in the United States and Uganda are quantitatively very different.
First, life expectancy in Uganda is 16 years less than in the U.S, 62.5 years vs. 78.5 years.
Second, 75% of the Ugandan population is under the age of 25, so the median age there is 15 and in the United States it is 38.3.
Third, the fertility rate in Uganda is 3% compared to only 0.6% in the U.S. The fertility rate measures the number of live births per 1,000 women of childbearing age, generally 15 to 44.
Uganda, though, lacks sufficient good infrastructure to support a population that is exploding with growth, thus making it impossible for the community to catch up and eradicate the infectious diseases brought on because of poor sanitation.
One rampant infectious disease that previous generations did not have to face is HIV/AIDS. It is rampant in the developing world, “an everyday, common disease,” according to Dr. Schaefle. Also, 75% of the world’s HIV/AIDS cases are in sub-Saharan Africa. The scope of this tragedy has many layers, but foremost is the inequitable distribution of health resources such as active antiretroviral therapy. Created in 1995, the therapy was available to patients in developed countries, where deaths from AIDS plummeted. Those same drugs did not reach rural Africa until 2005 or 2010, Dr. Schaefle said. The 10-15 year lag resulted in millions and millions of transmissions and deaths; even now, delivery of and access to the drugs is sporadic.
“HIV/AIDS is not a “headline disease” in North America and Europe, but it is very much a headline disease in Africa,” he says.
Gender roles explain a great deal why HIV/AIDS is so prevalent in Africa. Dr. Schaefle said women traditionally marry young, have at least one child soon after, and stay in their villages to farm and raise their children. The women typically want multiple children, but they want to be able to space out having their children instead of having a child every year. They are not mobile, especially once they have children, and tend to stay in and near their villages. They build strong community ties and develop friendships with the other women.
Men have an almost opposite experience. They leave their villages to find work that will pay in cash. They will work in construction, hire out for seasonal harvesting, drive taxis, and seek other itinerant jobs. The men do not have strong community ties and may be away from their wives and children for months at a time. They may also spend their time and money on drink and prostitution, which is likely how many of them contract HIV/AIDS. When they return home to their families, usually around Christmas, they have relations with their unsuspecting wives.
Even if both adults in a family contract HIV/AIDS, the progression of the disease is very different because of the gender roles. With their stronger community ties, women are more likely to go to the clinic regularly for medicine, receive help if they become sick, rely on neighbors to look after their children, and thus delay the trajectory of the disease. They are able to remain healthier longer. Men face a different outcome. Without a community to rely on, the men tend to avoid any self-care until they are ready to collapse. They show up at the hospital with opportunistic infections and have poor outcomes.
Poverty is another determinant in global health. Ugandans largely have enough to eat, but the country is cash poor. There is not enough money for anything to run smoothly and efficiently. At every step, individual Ugandans, as well as organizations like schools, hospitals, and businesses, make choices based on what is feasible given the available resources: school fees or medicine? electrical power to keep the toilets flushing 24/7 or just during the day?
The fourth aspect of global health is lack of healthcare infrastructure. In Africa, there are extreme shortages of physicians and nurses. It is difficult and expensive to get to a hospital. Once at the hospital, there is the cost of lost wages not only for the patient but for the one or more family members who accompany him or her. Patients admitted to a hospital must come with at least one family member because it is the family’s responsibility to feed, bathe and care for the patient. Most of that care falls to the women, who typically come to the hospital with one or more children. The wards are crowded and in disrepair. There is no privacy. There are shortages of nearly everything.
Dr. Schaefle first experienced the Kisoro clinic as a senior medical student at Einstein. After he completed a three-year residency at Lenox Hill Hospital in Manhattan, he was selected for a two-year Global Health Fellowship back at Einstein, delivering global and public health to patients in the South Bronx and Uganda and teaching medical students. At the conclusion of his fellowship, he was offered a position on staff as a member of the Global Health faculty.
Now in its tenth year, the partnership between Einstein and Kisoro is very real. Kisoro is “an accredited ambulatory site,” and thus funded largely from medical student tuition.
Doctors, medical students, and translators work side by side examining and caring for patients. Each of the medical students participating in the Kisoro clinic program admits and treats patients. With the help of their translator partner, the students learn how to take detailed histories. They learn how to conduct a thorough physical examination using only their stethoscope and other basic instruments. Time slows down as they lean in to know the patient before them as a whole person instead of a symptom. Most students find the month-long experience to be personally fulfilling as well as educational, he said.
As Dr. Schaefle wrapped up his presentation, many in the audience asked how they could contribute to the clinic, and he was happy to provide that information. One comment, submitted anonymously, as part of a post-lecture survey reads, “I enjoyed the presentation very much. It wasn’t hurried. Ken is an excellent speaker. I enjoyed learning about Ken’s work – the health clinic – the people and the culture. If I was 20 years younger I would be in Uganda helping Ken in the clinic. I’m a retired R.N.”
An encore presentation of the lecture may be found on the Levy Senior Center Foundation’s YouTube channel. Levy Lectures are always free, but registration is required. The next lecture, on Tuesday, October 27 at 1 p.m., will be a discussion with Jacqueline Saper about her book, From Miniskirt to Hijab, as she recounts her life in Iran before, during, and after the Islamic Revolution.