Introduction to Malawi: A Workshop on Chichewa Language and Malawi Culture

MalawiWorkshopWhen: Thursdays – March 26, April 2, April 9  & April 16 from 5:30-7:30 p.m.
Location: UNC Gillings School of Global Public Health, Room 2304 McGavran Greenberg

This four-part workshop will focus on introductory Chichewa greetings and linguistics, medical interview vocabulary, and cultural sensitivity in health services for UNC students, staff and faculty planning research, service or internships in Malawi.  Workshop sessions cover elementary language construction, health and cultural training, as well as brief presentations on the history, geography, politics and economy of Malawi.  Participants will be provided soft copies of readings and basic language material. Dinner will be provided. Attendance at a minimum of 3 sessions is required.

Space is limited – please register by emailing Mamie Harris at malawi@unc.edu . Also contact Mamie for additional questions or concerns.

This workshop is sponsored by the UNC Institute for Global Health & Infectious Diseases (http://globalhealth.unc.edu/) and the UNC African Studies Center (http://africa.unc.edu/index.asp)

Watch Video: David Margolis Talks HIV Cure, Med Adherence and New Strain

Malawians for Malawi: Creating a Sustainable Model of Care

Cecilia Kanyama, Gift Kamanga and Mina Hosseinipour work at UNC Project Malawi.

Cecilia Kanyama, Gift Kamanga and Mina Hosseinipour work at UNC Project Malawi.

UNC Project Malawi Associate Country Director Innocent Mofolo, MSc, remembers a time not too long ago when Malawians would come to the Kamuzu Central Hospital in the capital city of Lilongwe for cancer testing. However, a lack of proper diagnostic equipment and pathologists hindered immediate results.

“Samples had to be sent to Blantyre for testing and the turnaround time was three months,” Mofolo says. “Often times, the results would come after the patient had died.”

But now the Kamuzu Central Hospital, or KCH, is home to a histopathology laboratory and a pathologist thanks to a partnership between the University of North Carolina Chapel Hill (UNC) and the Malawi Ministry of Health. Since 1999, UNC Project Malawi has been based at Tidziwe Centre on the campus of Kamuzu Central Hospital. “Tidziwe” is a Chichewa word meaning “We should find out.” It is a fitting name as UNC staff has worked hand in hand with Malawians to “find out” the most beneficial ways to treat and prevent disease as well as train healthcare professionals to make UNC Project Malawi sustainable. Instead of staffing the center with a rotating group of UNC health professionals, most UNC staff has lived in Malawi for a decade or more and work to train Malawians to treat their countrymen.

“Malawian health leaders, including myself, are very skeptical of ‘helicopter medicine,’” says Senior Research Manager Gift Kamanga, MSc, DrPH. “We desire something that is sincere for Malawi.”

For more than 20 years, UNC Project Malawi has provided research, care and training in Lilongwe. The program serves as a model for creating sustainable health services in a developing country.

Training the Local Professional
UNC Project Malawi Scientific Director Mina Hosseinipour, MD, MPH, moved to Malawi in August 2001 and has been working there full time ever since.

“Our training contributions to local investigators and clinicians is immense,” Hosseinipour says. “UNC has trained internal medicine specialists as well as obstetricians and gynecologists who are actively working and teaching the next generation of medical students from the Malawi College of Medicine as well as providing care on the wards. This strong base of clinicians, accompanied by the long term presence of UNC faculty, has allowed the development of in-country training programs for OB/GYN and can support the eventual expansion of medicine programs.”

As the interest in training increased, diverse funding sources were sought including support from Gilead Sciences, Inc. and the U.S. National Institutes of Health (NIH) Fogarty AIDS International Training and Research Program (AITRP). The partnership with AITRP began in 1998 and the Gilead Training Fellowship began in 2008. Both programs support Malawians pursuing health degrees or residency trainings, usually at universities outside of Malawi. Lameck Chinula, MMED, participated in the AITRP to train as an OB/GYN at the University of Cape Town in South Africa. He is now UNC Project Malawi’s first Malawian OB/GYN.

Lameck Chinula is the first Malawian OB/GYN at UNC Project Malawi.

Lameck Chinula is the first Malawian OB/GYN at UNC Project Malawi.

“UNC has managed to sponsor specialty training for Malawian healthcare professionals, and I am one of the beneficiaries,” Chinula says. “These professionals have come back and held leadership positions in government and at UNC Project Malawi. There is a feeling of ownership of programs being led by the local healthcare professionals.”

Cecilia Kanyama, MMED, also went through the AITRP to complete a medical residency at the University of Cape Town. She is an internal medicine physician and infectious diseases researcher at UNC Project Malawi. She also teaches at the University of Malawi College of Medicine.

“The local health professional has more in depth knowledge of their own community and are also respected and involved in different forums for policymaking locally; hence, they are best suited to use the skills and knowledge acquired to ensure best medical practices that are relevant to local systems in the country,” says Kanyama. “This approach prevents the unnecessary turnover of staff, which may lead to poor continuity of programs. In addition, the local health professionals trained are instrumental in training others in their community long term.”

Portia Kamthunzi, MMED, has spent the past seven years as a physician a UNC Project Malawi specializing in treating malaria and pediatric HIV as well as preventing mother to child transmission of HIV. She feels the collaboration among foreign and Malawian health professionals has greatly benefited both groups.

“The UNC approach is a good one as local healthcare professionals are provided with skills and knowledge to improve healthcare in their own community,” she says. “And local healthcare professionals, who are knowledgeable about the local problems, are in a better position to tackle public health care issues in their communities.”

Access to Free Clinical Care
UNC Project Malawi provides free clinical care to over 1,700 patients per week. Services include women’s health, pediatrics and infectious diseases management.

“I can say throughout my time at UNC Project Malawi that my work has greatly improved the health of Malawians,” says Kamanga, who serves as Head of Sexually Transmitted Infections (STI) Clinical Services. “I implemented the government policy of routine HIV testing to all patients who come in for STI treatment. Almost 8,000 people accessed HIV testing and counseling from my clinic. Anyone who tests positive is linked to antiretroviral therapy.”

Agnes Moses

Agnes Moses is a clinician and researcher at UNC Project Malawi.

Agnes Moses, MMED, witnessed the effect antiretroviral therapy access is having on Malawians firsthand. Like Kanyama, she completed the Gilead Training Fellowship and works as an internal medicine physician at UNC Project Malawi.

“During my first two years at the Project, I was leading the UNC initiated Preventing Mother to Child Transmission (PMTCT) program,” Moses says. “I had the pleasure of observing twins born to the first mother we gave nevirapine prophylaxis to within the program and her twins were born HIV-free. They are now 12-years-old.”

Moses’ specialty is cancer treatment. Another moment that stands out during her 13 years with UNC Project Malawi is the recovery of a man living with HIV and cancer.

“Four years ago I was running a cancer clinic at a referral hospital and we had a patient living with HIV and non-Hodgkin’s lymphoma,” Moses says. “He was treated with drugs donated by UNC and remains cancer-free.”

The Malawian health professionals also credit the acquisition of modern technology, like the use of digital X-rays in the radiology department, to improving clinical care.

“UNC Project Malawi has supported infrastructure development like the short-stay ward, and equipment like the first laparoscopy unit for the surgery department and a colposcopy unit for the OB/GYN department,” Mofolo says. “The partnership between UNC and the Malawi government is invaluable.”

Malawians Learn of Research Results
Results of research studies conducted at UNC Project Malawi continue to change treatment guidelines and inform healthcare policies. Hosseinipour specializes in HIV research including vaccines, injectable pre-exposure prophylaxis, prevention of mother to child transmission, treatment as prevention and management of opportunistic infections like Kaposi’s sarcoma.

“UNC Project Malawi research has directly influenced Malawian policies for treatment and prevention of HIV,” says Hosseinipour. “For example, findings from our Breastfeeding and Nutrition (BAN) study and the HIV Prevention Trial Network (HPTN) 052 study have directly influenced the expansion of antiretroviral therapy (ART) to mothers and the increase of CD4 threshold for ART initiation. These policy decisions have transformed the health of HIV infected individuals, essentially making HIV a manageable, chronic disease.”

Tisu

Tisungane Mvalo realized the power of the work he was going in Malawi during a malaria study.

Tisungane Mvalo, MMED, remembers workings as the co-investigator of a previous malaria trial when he had the powerful realization that the research he was doing at the Project was providing the clinical care and management for 1,600 Malawian children on a 24-hour basis.

“With the 24-hour clinical care for these children provided, I had a feeling that we were improving the health outcomes for these children,” he says.

No matter what condition is being studied at UNC Project Malawi, research results are always shared and this transparency impresses Kamanga.

“Every year, UNC Project Malawi supports initiatives to disseminate health research in Malawi at the Malawi College of Medicine,” Kamanga says. “This is where the Project’s research results are disseminated first to Malawi, as the primary beneficiary. It is very satisfying for me as a Malawian to work with a partner to Malawi like UNC that is committed to the principle of genuine capacity building.”

Fogarty Fellowship Gives UNC Grad Confidence to Excel in Research

Kathy Lancaster leading a training in Malawi.

Kathy Lancaster leading a training in Malawi.

A year ago, UNC doctoral candidate Kathy Lancaster found herself sitting in a bar in Lilongwe, Malawi, with her outreach team talking about sexual health with Malawian sex workers. The conversation marked the initial step in enrolling women in Lancaster’s study exploring how substance use affects the HIV care continuum. Now back in Chapel Hill, Lancaster is using the data she collected in Malawi to write her dissertation and submit the study results to scientific journals. The entire experience is a dream realized for Lancaster and she is thankful her mentors introduced her to the UJMT Fogarty Global Health Fellowship.

“Fogarty is a unique opportunity for students, especially those on the PhD track, to have the resources needed to conduct a study,” Lancaster says. “A lot of times you get short snippets of research or you are involved in the analysis, but to really be the driving force behind your own project and your own success is a unique opportunity.”

Click here to watch a short video of Lancaster sharing how the Fogarty fellowship shaped her as a young researcher.

Originally a veterinary science major, an epidemiology of infectious diseases elective sparked a change in career paths.

“That class showed me how disease affects more than the individual suffering from it,” Lancaster says. “Disease impacts whole communities.”

Her first taste of international global health research also occurred during her undergraduate degree when she traveled to Peru to work in a parasitology lab. Lancaster returned to the US and decided to continue her studies pursuing a master’s degree in public health with an epidemiology focus from Tulane University. She then came to UNC for her doctorate. A discussion about her dissertation with her mentors Irving Hoffman, PA, MPH, and Bill Miller, MD, PhD, MPH, led her to the Fogarty program.

“It’s pretty unusual for a doctoral student in our epidemiology program to run her own study to collect the data for her dissertation,” says Miller. “Kathy developed the research question, worked out all the details for the study, and managed to pull it off. It is really a huge accomplishment. Since she came, Kathy has shown great initiative and this study is just one example of that.”

The UJMT Fogarty Global Health Fellowship Consortium provides an opportunity in global health research training for selected junior faculty, postdoctoral fellows, and pre-doctoral scholars. This 11-month-long mentored clinical research training program is sponsored by the Fogarty International Center and other National Institutes of Health (NIH) Institutes, Centers and Offices. Lancaster had two weeks from first learning about the Fogarty program until the application due date. She said the time crunch forced her focus on designing her project.

“It was really exciting,” she recalls. “The idea of traveling and living in another country where I could conduct my research appealed to me.”

Kathryn Salisbury is the UJMT Fogarty Global Health Fellowship Program Manager.

“Kathy applied as a pre-doc to the Fogarty Global Health Fellowship (FGHF) Program in 2012, and since that time she has been a remarkably pleasant person to work with,” says Salisbury. “The Fogarty award funded Kathy’s dissertation research on drug use and HIV testing in a population of female sex workers in Lilongwe, Malawi. It has been terrific to watch her succeed in conducting this project within the short 11- month fellowship time frame. While circumstances around conducting research in a low-and middle-income country setting are often challenging, Kathy’s focus and hard work kept her project on track as she was able to manage well a wide range of competing demands.”

UNC Project-Malawi team practicing with the Pima machine for rapid CD4 counts.

UNC Project-Malawi team practicing with the Pima machine for rapid CD4 counts.

Once arriving in Malawi, Lancaster first had to gain the trust of the sex workers she hoped to enroll in her study. She worked with her outreach team made up of UNC Project-Malawi and Theatre for a Change staff and would visit the bars the women worked in during the day to explain what her study entailed.

“Prior to formal interviews with the sex workers, I sat down with them,” Lancaster says. “They were actually excited to be the focus of my study because they felt most times HIV prevention, testing and treatment focuses on the general population and not them.”

Lancaster spent a year in Malawi gathering data about how alcohol and other substances influence each step of the HIV Care Continuum. The HIV Care Continuum, also called the HIV Treatment Cascade, outlines the steps from testing to treatment. These stages include diagnosis, linkage to care, retention in care, antiretroviral therapy prescription and viral suppression. She will use this information to write her doctoral dissertation and hopes to have her research results published in scientific journals.

“I also want to take what I learned through the Fogarty and design an intervention for female sex workers and tailor this intervention to fit their unique needs to increase their access to HIV care and treatment,” Lancaster says. “Hearing the excitement in the women’s voices when I interviewed them was an immediate affirmation for me that I am in the right line of work. Engaging with the women and learning about their lives is something I would not have experienced unless I was there living in Malawi.”

Her work in Malawi earned her the 2015 Conference on Retroviruses and Opportunistic Infections (CROI) Young Investigator Award. She will travel to Seattle to accept the award at the end of February. Once she finishes her doctorate, Lancaster will work with Miller on another population at high-risk for becoming infected with HIV people who inject drugs in Asia and Eastern Europe. She feels the Fogarty fellowship prepared her for a career in global health research.

“What I’ve learned so far is that there are these key populations inside generalized epidemics that have a high concentration of HIV infection. And these unique populations, like sex workers, have barriers to accessing HIV testing, care and treatment. In order to achieve HIV eradication, it will be imperative to keep these populations engaged and identify ways to increase their access to testing, treatment and care,” Lancaster says. “The Fogarty gave me the chance to refine my skillset, but also gave me the confidence needed to be a successful researcher.”

New Accountant Reconciles $1.3 million in Three Weeks

Debbie Dickerson

Debbie Dickerson

As a new accounting technician in UNC’s Institute for Global Health & Infectious Diseases (IGHID), Debbie Dickerson had no idea she would make such a big impact so quickly. In three weeks, Dickerson reconciled $1.3 million worth of outstanding charges.

“All charges from June to Nov. 30, 2014, had to be invoiced by Jan. 15, 2015,” Dickerson says. “I needed to provide UNC’s Office of Sponsored Research (OSR) with hard copies of the receipts as well as upload an electronic version and spreadsheet to PeopleSoft. OSR then provides the funding agency with a report. Without this report, future funding could have been jeopardized.”

Dickerson had never used PeopleSoft before, but with the Jan. 15 deadline looming, she hit the ground running. All of the charges were incurred by UNC’s Project Malawi. The Project, based in Lilongwe, Malawi, receives cash advances to pay for salary support, office supplies, fuel and travel. Dickerson needed to request receipts showing exactly how the cash advances were spent. She then reviewed each charge to ensure expenses were allowable according to UNC and the funding agency’s guidelines. Despite the seven-hour time difference between Chapel Hill and Lilongwe, Dickerson was able to connect with UNC Project Malawi staff and quickly gather the information she needed.

“I had emails and emails of receipts, literally thousands of pieces of paper,” she says. “I spent one entire day at the copy machine.”

Diana Stanley is the IGHID International Business Officer. She manages Dickerson and was impressed with her work ethic.

“Reconciling cash advances is a very cumbersome and time-consuming task due to its many steps,” Stanley says. “Debbie, never having reconciled receipts before, was able to accurately identify errors, address the problems and reconcile the receipts accordingly. Due to her hard work, our team was able provide OSR with the needed information, allowing them to provide financial reports to the sponsors. We are very happy to have Debbie as part of the IGHID accounting team.”

Dickerson has gone from a PeopleSoft novice to a pro.

“I’ve got it down,” she says with a laugh. “I enjoy the work. I am never not busy.”

More than likely, Dickerson will never have to reconcile that amount of money again. There is now a 30-day timeline to submit receipts.

Watch & Listen to Friday Morning Conference

Julia Sung Receives Competitive KL2 Program Funding

Julia Sung, MD

Julia Sung, MD

During her medical residency at Johns Hopkins in Baltimore, Julia Sung, MD, cared for young adults infected with perinatal HIV. It is hard for a person of any age to remember to take medications daily, especially a child. Thus many of her patients had stopped and started antiretroviral therapy (ART), causing drug resistance that hindered treatment of their disease in later years.

“These are young adults who have been robbed of a normal life,” she says. “Decisions they made as adolescents about taking their medications continue to affect them today as they struggle to control their HIV. I just kept thinking that there had to be a better solution.”

Many other patients Sung treated were afflicted with comorbidities that were not wholly alleviated by ART. These patients and the people she treated who were infected at birth weigh on her mind as she completes her research fellowship at UNC and prepares to come on board as faculty this summer. To try and find an alternative to ART for these patients, Sung decided to apply for a KL2 training. The program seeks to provide two to three years of research funding to clinician scientists who show interest in interdisciplinary, domestic projects. The training is sponsored by UNC’s Translational and Clinical Sciences Institute or TRACS. Each year, four to six applicants are selected.

“I will be working on enhancing the clearance of latent HIV,” Sung says. “This is research at the nexus of virology and immunology.”

Listening to speakers at a Center for AIDS Research (CFAR) event introduced Sung to David Margolis, MD, her current mentor. Margolis leads CARE or the Collaboratory of AIDS Researchers for Eradication. He is also the Director of UNC’s Institute of Global Health & Infectious Diseases Program in Translational Clinical Research.

“It takes a good juggler to become a jack of all trades: doctor, scientist, fundraiser and author. But that is what it takes to bring discoveries into the clinic to improve medicine,” says Margolis. “Julia is trying to do all of this while raising two young kids. So I know she is already a good juggler.”

Sung’s other mentor is immunologist Nilu Goonetilleke, PhD.

“Julia is an exciting young investigator. She does the right preparation and has the right combination of talent and drive,” says Goonetilleke. “I look forward to what we can learn together.”

Sung will spend the majority of her time at UNC over the next two to three years working with Goonetilleke and Margolis on strategies to eradicate HIV. Near the end of her time as a KL2 Scholar, Sung will apply for an individual training award through the National Institutes of Health (NIH) to further her along the path of becoming an independent researcher. The patients she met years ago in Baltimore will always be her motivating force.

Nurse Values Learning from Colleagues

Margolis’ HIV Cure Research Featured in The New Yorker

Becoming Less Super as a Specialist

By David Wohl, MD

David Wohl, MD, traveled to Sierra Leone to care for people infected with Ebola.

David Wohl, MD, traveled to Sierra Leone to care for people infected with Ebola.

There are specialists and then there are the super-specialists. The ‘super’ here should be taken less as a superlative and more as a suggestion of beady-eyed focus and a lack of breadth. Instead of knowing a lot about something special, super-specialists know a lot about a part of that special something. Picture the entomologist whose career has been dedicated to the gut of one particular species of ant, or the historian fascinated by the life of one U.S. vice president. What do you see? Probably someone who is not all that fun to have at a dinner party.

I am a super-specialist. It’s okay, I own it. In fact, I have been proud of it (and I am pretty good at dinner parties). Microbiology and infectious diseases may have been my favorites in medical school, but it was HIV that pulled be over the buggy side. Sure, I dutifully completed an infectious diseases fellowship and every decade I sit for that discipline’s certification board examination. But the truth is I am really an HIV-ologist in infectious disease specialist’s clothing. All but a handful of my patients are HIV infected. The journal articles I actually do read are almost always HIV-related. I attend only conferences dedicated to HIV/AIDS.  Don’t get me wrong, hanging around an ID division, I do pick up some factual knowledge of lesser pathogens such influenza, cholera, and Malassezia furfur. But, what I know of these and other non-HIV germs is not half of what I know about HIV. HIV is what I do.

Well, now it is not the only thing I do. A few months ago, something new started to pull me from the HIV doc ranks. Ebola.

HIV doctor takes on Ebola: it is a story we have heard before and it should not be a surprise. Much has been written about the parallels between HIV and Ebola: uncontrolled spread, fear, stigma, risk. The current massive and unprecedented outbreak has claimed over 8,000 people this year, many of them young. As in the early days of the HIV epidemic panic has replaced reason, lack of coordination has delayed response and all the while people die. It is déjà vu all over again and last August, when the director of Doctors Without Borders called for clinicians to step up to combat a burgeoning Ebola outbreak in West Africa, I applied. All infectious diseases and HIV providers, I felt, needed to at least ask themselves if they could and should respond to the outbreak of Ebola.

Without level 4 pathogen or outbreak response experience, I was not what Doctors Without Borders wanted. But, it turns out this was for the best, as I realized that a better way to tackle Ebola was to apply my clinical research skills – experience honed by my focus on HIV.

Tales of what I have been doing and have seen in West Africa can be saved for another time. As I type while flying back from Sierra Leone, I am wondering how it was that I became so dedicated for so long to one pathogen, albeit the cause of a pandemic that has killed millions and has significantly altered many aspects of modern medicine. Moreover, I reflect on how it came to be that I was pulled from this comfortable orbit by this even more sinister infection. Perhaps it is the particular monstrosity of Ebola that created my urge to respond – just as the swiftly spreading and devastating AIDS crisis of the 1980’s attracted me so strongly then.

Nagging at me, though, is an inkling that there is more to my motivation to respond than the overlap between HIV and Ebola. Can it be that now that HIV medicine has become largely a routine of well visits among people living with undetectable levels of the virus in their blood, when we track LDL cholesterol more closely than CD4 cell counts, that I and other HIV providers are seeking the excitement and novelty we once had? Are we increasingly becoming susceptible to the lure of the next big thing, be that HCV or, for some of us, Ebola?  Our victory against HIV has been accompanied by the loss of intensity that drove many of us to the fight against AIDS. And, so, no wonder that our gaze falls elsewhere.

I have to believe that I am driven toward Ebola by more than some sort of professional mid-life crisis; that my deciding to be involved reflects a commitment to help make things better for those infected and affected by this horror. Yet, I am also aware that why we do what we do is complicated.

I am not giving up my day job and will continue to be an HIV doctor until there is no HIV. Yet, I have to break the news to HIV that I have started seeing another virus. It is scary and wild and thrilling and it is also something I feel I have to do– just like back then, when young men started getting sick and I, along with many others, felt we had to come calling.