Global Health Track in Pulmonary and Critical Care

Chronic diseases affect people of all ages, nationalities and classes and cause the greatest share of death and disability, accounting for around 60% of all deaths worldwide yearly, 80% of which occur in LMICs. The effect of chronic disease is projected to increase quickly in the low and middle income countries, where it is expected to cause seven out of every ten deaths in 2020 as compared with less than half that number in 2005. Non-communicable pulmonary diseases represent a large component of the burden of chronic diseases. To address the growing burden of chronic pulmonary disease, there is a need for leaders with skill sets in global health research, health delivery and medical education.

As the global burden of lung disease transitions from individuals living in high income countries to those in low- and middle-income countries, there is a growing need to develop clinicians and researchers with internationally focused training. Similarly, the implementation of intensive care units in resource-limited hospitals combined with global campaigns to address early sepsis have shifted the focus of critical care onto a global scale which will require additional background and skill sets. The proposed global health pathway will train up to 1 fellow per year in the global health aspects of pulmonary based diseases and critical care medicine over the course of four years. The pathway will integrate throughout the Pulmonary and Critical Care Fellowship at Johns Hopkins School of Medicine with the goal of training fellows who have the necessary skills to pursue academic careers with research and/or leadership in global pulmonary and critical care medicine.

COPD is a leading cause of mortality and morbidity worldwide. Currently, COPD is responsible for 5% of all deaths and ranks as the sixth most common cause of death in low and middle income countries. By 2030, COPD is expected to become the fourth cause of death after ischemic heart disease, pneumonia and stroke. The two most common risk factors for COPD are tobacco smoke and exposure to biomass fuel smoke. Tobacco use is the leading cause of preventable death in the world, resulting in millions of deaths annually: more than HIV/AIDS, tuberculosis, and malaria combined. Biomass fuel smoke is a unique risk factor to low and middle income countries and is responsible for 35% of COPD cases, and more than 90% of the developing world uses solid fuels indoors for cooking or heating. Biomass fuel smoke is responsible for 1.6 million deaths and 38.5 million disability adjusted life years lost each year, or 3.5% of global burden of disease. Women and children are the most vulnerable because they spend more time indoors, and are thus likely to develop long-term pulmonary complications. Our work has included original research on biomass exposure in Nepal, Peru and Uganda. We have active studies in Uganda and Peru concerning COPD epidemiology, risk factors and cook stove interventions.

Asthma has emerged as one of the most prevalent non-communicable diseases worldwide. The World Health organization estimates that 300 million people suffer from asthma and 255,000 people died from it in 2005. Asthma is responsible for 15 million disability adjusted life years lost each year, which accounts for 1 percent of all disability life years lost, which is comparable to that of diabetes mellitus or cirrhosis. A worrisome statistic is that over 80% of asthma-related deaths occur in low and middle income countries, where it disproportionately affects children and the poor. As asthma prevalence is only expected to increase, the numbers of individuals affected and the overall burden of disease caused by this syndrome are expected to worsen. Risk factors for asthma include atopy, diet, obesity, smoking, indoor and ambient air pollution including proximity to roadways, and urbanization. Our research includes epidemiology of asthma among children and adults in Peru and Uganda as well as assessments of system level policy interventions that can improve disease management.

Critical Care is a growing field of medicine in LMICs. Implementation of known effective therapies is an important target in the provision of high quality care of critically ill patients. From a global perspective, the potential benefit of interventions shown to improve survival associated with mechanical ventilation is expected to be large. It has been reported that survivors of mechanical ventilation experience a much greater increase in disability than survivors of hospitalization without mechanical ventilation. The past decade has witnessed numerous randomized trials related to reducing the need for mechanical ventilation, reducing the duration of mechanical ventilation, and improving safety of mechanical ventilation (e.g., trials of lung-protective ventilation). The use of intensive care and, in particular, mechanical ventilation in Peru has increased markedly during the last decade.

Translation of knowledge from clinical research to clinical practice and public policy is needed to affect current practices and long-term outcomes of patients with chronic pulmonary conditions. While the epidemiology and pathobiology of chronic lung diseases such as obstructive lung diseases (asthma, and COPD), cardiopulmonary complications in high altitude dwellers (CMS and HAPH) and the long-term complications from critical illness are better understood, the translation of this understanding into improved health outcomes has not kept pace. In previous years, preventive strategies have been attempted globally to prevent the explosive growth in the burden of chronic pulmonary diseases.

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Fellows invited to participate in the Global Health Track will be:

  • Exposed to global health concerns relating to lung disease and critical care.

  • Trained in research methodology and grantsmanship necessary to develop an internationally focused clinical, basic science and translational research agenda.

  • Mentored in pursuing a successful academic career in global health within the field of pulmonary and critical care.

We will utilize existing collaborations between the Johns Hopkins School of Medicine (JHSOM), Johns Hopkins Bloomberg School of Public Health (JHBSPH) and our affiliated international sites at Universidad Peruana Cayetano Heredia (UPCH) and A.B. PRISMA in Peru, Makerere University College of Health Sciences in Uganda (MU), and the Tribhuvan University Institute of Medicine (IOM) in Nepal, leverage collaborations at other institutions in multiple countries with Pathway Faculty to stimulate interdisciplinary communication and facilitate creative collaborative research across participating institutions, as well as with other partners in Latin America, Africa, and Asia. Trainees in the pathway will develop their own research niches in which they can become leaders of productive, collaborative high impact research. This approach promotes the development of successful scientific careers and will be the key element in the success of this program in training academic scientists in chronic pulmonary diseases. The combined resources of JHSOM, JHBSPH, UPCH, MU, and IOM will support an innovative and multidisciplinary chronic pulmonary research training program with the goal of training the next generation of leaders in global health and pulmonary and critical care medicine. Given the paucity of experts in chronic pulmonary diseases in the field, this training program represents an opportunity to strengthen local research capacity and infrastructure in our partner countries, an important area of medicine and clinical research.

All trainees participating in the pathway are expected to have international exposure prior to entering fellowship. Fellows will have internationally focused elective experiences (attending asylum, TB or travel clinic) as well as didactics at the Johns Hopkins Bloomberg School or Public Health (Chronic Diseases in Low and Middle Income Countries course). Funding sources for research years in the Global Health Track include the UMJT Fogarty Global Health Fellows and Scholars Program where fellows will be required to write an internal but competitive grant application which would outline their research for the year and will have the opportunity to work at established research sites in Peru, Bangladesh, Uganda, and Nepal as part of existing research projects. Fellows will meet bi-weekly with others in the pathway for research-in-progress, career mentoring, and global health grand rounds. The elective would set the stage sets the stage for the submission of career development award applications (e.g. individual NRSA award, the Parker B. Francis Fellowship in Pulmonary Research, American Thoracic Society and American Lung Association Fellowship Award, and ultimately K series awards) to support trainees career development in academic Pulmonary and Critical Care Medicine and Global Health. Fellows will be encouraged to submit work at national/international meetings such as the American Thoracic Society International Conference, Consortium of Universities for Global Health, or the International Union against Tuberculosis and Lung Disease World Conference on Lung Health.

Core Competency Areas Objectives
Clinical Knowledge Develop a comprehensive understanding of the global burden of respiratory and critical illness, including:
  • Knowledge of the global epidemiologic distribution of major infectious and non-communicable diseases imparting morbidity and mortality
  • Social, environmental and economic determinants of health, including how host, environmental and health systems-based factors govern health worldwide
  • Identification of the clinical presentation and management of complex diseases in resource-limited settings through completing didactic coursework concerning major pathological processes (e.g., malaria, tuberculosis, viral hemorrhagic syndromes, HIV), their biological alterations, and how they affect specific organ systems.
Global Health Research Training Complete didactic coursework and receive mentorship from domestic and international investigators, focused on developing an understanding of the unique cultural, legal and societal considerations required of research conducted in low- and middle-income countries, including:
  • International research ethics and human subjects protection
  • Needs assessment, including community-based involvement, to generate locally relevant research
  • Study design and implementation
Cultural Competency Cultivate and develop awareness of the attitudes, beliefs and processes that facilitate the doctor-patient relationship and allow effective partnership across international clinical and research collaborations by:
  • Actively participating in seminars regarding cultural beliefs
    and practices of international training sites
  • Establishing mechanisms to address conflict resolution in international clinical and research settings
Clinical and Research Capacity- Building Actively participate in clinical and/or research capacity building with a focus on sustainable, longitudinal partnerships by developing:
  • “Train the trainer” educational models to develop local subspecialty expertise, ultimately aimed at local clinical and research independence
  • Multi-level participatory needs assessments with international stakeholders

Department of International Health (JHBSPH) Baltimore, USA: The Department of International Health is a multi-disciplinary environment whose mission is to “understand health problems and develop means of disease reduction and health protection in underserved populations around the world. International Health draws on all public health disciplines for application in global settings and emphasizes masters and doctoral training programs for students with international and cross-cultural interests”. Faculty research includes the implementation of cost-effective strategies for health care delivery; the design of health promotion interventions to disadvantaged communities; conducting laboratory studies to develop vaccines; clinical trials, prevention trials, behavioral studies, and the development of policy for disease control; and the development of methods to assess nutritional status and to propose effective strategies for nutritional diseases.
http://www.jhsph.edu/departments/international-health/index.html

Universidad Peruana Cayetano Heredia, Peru: The Center of Excellence for Chronic Diseases (CRONICAS) based at Universidad Peruana Cayetano Heredia (UPCH) was the first research center in Peru dedicated to NCDs and supports longitudinal studies being performed in three settings in Peru. The study group has made significant scientific contributions in the field of non-communicable disease epidemiology in Peru including COPD and associated risk factors. Our in-country collaborator is Jaime Miranda, MD, MSc, PhD, Associate Professor at UPCH and Director of the CRONICAS Center of Excellence in Chronic Diseases in Lima, Peru, and a UK-trained epidemiologist.
http://www.cayetano.edu.pe/cayetano/es/

Asociación Benéfica PRISMA, Peru: A.B. PRISMA is a Peruvian non-profit, non-governmental organization dedicated to supporting sustainable human and economic development through projects in health, nutrition, agriculture, and projects that improve incomes and provide access to economic opportunities for these populations. A.B. PRISMA has a national staff of over 400, a quarter of whom are medical and other health professionals, located throughout its Lima-based central office, six regional offices, and 16 satellite offices. Our in-country collaborator is Dr. Marilu Chiang MD MPH, Head of Human Development has more than 20 years of experience in implementation science activities in Peru.
http://www.prisma.org.pe/

Makerere Lung Institute, Uganda: The Makerere Lung Institute (MLI) is located within the College of Health Sciences at Makerere University, conducted the FRESH AIR study (the first population based COPD survey in Uganda) with funding from the International Primary Care Respiratory Group. Subsequently MLI has conducted awareness and education projects on biomass fuel smoke. Our in-country collaborator is Bruce Kirenga MB ChB, MMed is a lecturer of Pulmonary Medicine and Director of MLI. http://chs.mak.ac.ug/

Institute of Medicine, Nepal: The Institute of Medicine (IOM) of Tribhuvan University is the premier institution for training in Medical Sciences in Nepal. IOM has 29 different programs from proficiency certificate level to the highest postgraduate degree in medicine, public health, paramedical, nursing and traditional medicine through nine campuses in Nepal.  Our in-country collaborator is Prof. Laxman Shresthra MB ChB, is Head and Professor of the Department of Pediatrics at IOM. http://www.iom.edu.np/

US-based Global Health Mentors:
William Checkley, MD, PhD (COPD, critical care, asthma)
Suzanne Pollard, PhD (asthma)
Nadia Hansel, MD, MPH (asthma, COPD)
Robert Wise, MD (asthma, COPD)
Alan Schwartz, MD (Sleep Medicine)
Jonathan Golub, PhD (Diabetes and tuberculosis)
Amita Gupta, MD (long-term sequelae of tuberculosis)
Petros Karakousis, MD (tuberculosis)

LMIC-based Global Health Mentors:
Marilu Chiang, MD, MPH (Household air pollution)
Stella Hartinger, PhD (Household air pollution)
Bruce Kirenga, MB ChB MMed (COPD, asthma)

The Pulmonary and Critical Care Fellowship accepts eight fellows per year for at least three years. We will invite up to one of the eight fellows each year to join the Global Health Track .  All fellows are are accepted through the NRMP and applications are accepted through ERAS beginning around July 1.
For more information on how to apply to the Pulmonary and Critical Care Fellowship, please visit our website (http://www.hopkinsmedicine.org/pulmonary/fellows/) or contact the Fellowship Coordinator Jeannie  Amoss (jamoss@jhmi.edu) or the Fellowship Director Prof. Henry Fessler (hfessler@jhmi.edu).