Dispatches - Fall 2003
The last place Jackie Agnew expected to find herself at the end of the semester was in a room filled with tear gas, checking to see if her gas mask was a good fit.
“They take you into this gas chamber, which is nothing more than a concrete blockhouse with a door, and they have you move around, talk, jump up and down to make sure there aren’t any leaks,” she says of the experience. “You know right away if your mask fits.” Luckily, hers did.
A professor in the Department of Environmental Health Sciences whose expertise lies in workplace and environmental exposures to chemical, biological, and radiological agents, Agnew directs the Johns Hopkins Education and Research Center for Occupational Health and Safety (ERC). She is also a colonel in the U.S. Army Reserves, which is how, last April, she found herself conducting gas mask drills in Fort Campbell, Ky. Her unit—the 309th Medical Group based in Rockville, Md.—was called up last March as part of the general mobilization for the Iraq invasion. Although Agnew, RN, MPH ’78, PhD ’85, and the members of her unit participated in the same chemical warfare drills as the soldiers departing for the Middle East, their work was strictly stateside, related to the command and control of the Army’s frontline medical units. “We’re like air traffic controllers for medical assets,” is how Agnew describes it. “We’re the ones charged with figuring out where hospitals will set up, and how you arrange to get casualties to them.”
At Fort Campbell they were primarily engaged in training for a combined military-civilian response in the event of a major terrorist attack on U.S. soil. In particular, they developed plans to respond in the event of a domestic chemical, biological, radiological, nuclear, or high-yield explosive (CBRNE) event. These kinds of attacks, which have only been seriously contemplated since the events of 9/11, call for a larger, more comprehensive response than disasters typically described in civil defense manuals. “CBRNE events are different in that they are much further-reaching than a train derailment or a tornado or some other typical emergency situation,” says Agnew. “Because of this, they necessitate interaction among agencies and organizations that may not have a lot of experience interacting—especially among civilian and military agencies.”
When Agnew’s unit got to Fort Campbell, they immediately began training in suitable responses to CBRNE events. “This entire concept is so new that no one knew precisely what should be done,” she says. “There was no manual.”
As it turns out, the 309th had a tremendous asset in Agnew. Just a few months earlier, the ERC had organized a two-day conference in Baltimore aimed at determining a training model for the professionals who would be called upon to respond to a CBRNE event. “We had over 200 participants from across the country,” she says.
Deactivated and returned to its Rockville base in July, Agnew’s unit will continue to work on increasing CBRNE event readiness. “One of the most satisfying aspects of what we did was that it showed the benefit of using reservists,” she says. “We understand the civilian system, and could provide an interface between the civilian and military sides. In the section I led, I had representatives from the private sector, the Coast Guard, the Navy, the FBI, and the USDA, and the professionals included researchers, industrial hygienists, and even a chaplain. They brought an understanding of different systems that would be essential in the event of an emergency.”
They came to be counted—46,000 of them—and to raise a sweat on their country’s behalf. On November 23, 2002, they assembled in Bangkok’s grand concourse, the Sanam Luang, not far from the Royal Palace. The prime minister was there, as were members of his cabinet and Thai citizens from all walks of life. For 61 minutes, the largest aerobics class ever assembled on earth stretched, bounced, and slid right into the pages of the Guinness Book of World Records.
In Thailand, the preeminent public health threats have changed from malnourishment and infectious diseases to heart disease and other chronic illnesses. The giant aerobics class was the government’s way of demonstrating its intention not to treat these new challenges lightly, says Vallop Thaineua, MD, MPH ’76, permanent secretary to the country’s Ministry of Public Health.
In 2002, Thaineua became the highest ranking, non-political appointee in Thailand’s health ministry. One of his first priorities was to get the people of Thailand up and moving. “By the end of 2003 about half the population will be participating in exercise,” he says. “Now, in almost every village people are doing exercises. The young are running, the older people are doing aerobics.”
More recently, Thaineua has helped turn his country’s attention to food safety. “Thailand is known worldwide for its tasty food, and we are determined that the hygiene of our food should be world class,” says Thaineua. For the past two years, he has been promoting the “Clean Food, Good Taste” project, aimed at improving hygiene in every phase of food production.
When SARS arrived in the Philippines, Jean-Marc Olivé was one of the first to know. As representative for the World Health Organization (WHO) there, Olivé, MD, MPH ’80, learned that a native Filipino was the business partner of one of the first people to die from a strange new illness recently identified in Hanoi, Vietnam. This was before the term SARS—severe acute respiratory syndrome—had been coined, before the WHO began an unprecedented worldwide alert to contain the disease. The Filipino had developed diarrhea and other signs of illness soon after his partner’s death. He was sick, he was scared, and one more thing—he was coming home.
“We were quite lucky,” says Olivé of what happened next. “We were able to track the man down and convince him to go to a hospital, where we had him isolated.” As it turns out, the man soon recovered. But Olivé thinks the false alarm was a big help. “We right away began developing strategies and procedures, so we were a bit primed when the first case actually arrived.
“We had two and a half very ‘hot’ months—it was very tense,” he says. “The health infrastructure in the Philippines is weak, and it was thought if SARS got here it would be a huge problem.”
The WHO was particularly worried about the Philippines because of its unique economy. Nearly 10 percent of Filipinos live and work abroad. Early in the outbreak, Filipino nurses died in Hong Kong and Singapore. At that time, there were at least 10 flights a day from Hong Kong to the Philippines. WHO authorities worried that all the Filipino overseas workers returning to the country could be prime vectors for the disease.
“By this time SARS was all over Singapore and Hong Kong, but the Philippines had yet to report its first case,” Olivé remembers. “People were thinking we were withholding information. Officials in Geneva [WHO headquarters] had difficulties understanding that no case of SARS had yet been identified.”
Overall, the Filipino response was impressive—and effective. “We only had 12 cases and two deaths, and all of the transmission occurred within the hospital, with no risk of infection in the community,” says Olivé. Even so, he had heated discussions with WHO in Geneva about the type of transmission occurring. “All of it occurred in the hospital, but the Philippines was put on the list of ‘B’ countries—meaning there was ‘community transmission.’ As soon as the country was listed, it was a disaster,” he says. “Many countries issued travel bans to the Philippines, and many Filipino overseas workers could not get back to their workplace.”
Eventually, the country was removed from the list and certified safe. Olivé credits two factors for the success of their efforts: political commitment at the highest level, and the tremendous work of local epidemiologists in tracking and isolating all contacts of the index cases, thus preventing transmission to the community.
When Swaraj Rajbhandari returned to her native Nepal last year after two and a half years working overseas, she found herself face to face with the great scale of one of the problems confronting women in her country. To the usual challenges inherent in improving child and maternal health in any developing nation, consider adding the world’s tallest mountains. “While it’s good to be back, I was reminded that our system of health care faces many obstacles,” says Rajbhandari, MBBS, MCPS, MPH ’99. “The country is very mountainous, and it is often impossible to get a woman to a health center in case of an emergency. There are also shortages of manpower, especially in remote areas. These women can’t get to a hospital in an emergency.”
Trained as an obstetrician/gynecologist, Rajbhandari now works as a reproductive health specialist charged with strengthening the government health system. Although her primary duties involve work at the national level in the capital city of Kathmandu, Rajbhandari has had the opportunity to see firsthand how topography can impede even the most ambitious plans for health care delivery.
“I was in Jumla, a remote district in western Nepal, where a team of 18 doctors and 12 nurses and other supporting staff went to do a health camp,” she says. “It was supposed to be just a GYN camp, but in the short time we were there I had one woman come in who was bleeding at term and we had to do an emergency cesarean [section], and another who had a ruptured ectopic pregnancy. It was purely luck that we were there. Otherwise, she would have died. In these remote regions, if the couple cannot afford to fly her to the hospital, the woman dies.”
And yet, in the fight to save lives and improve health, it is not just the mountains but more familiar obstacles that Rajbhandari must overcome. “Factors impeding women’s health are the result of their relative low status in society, which leads to poor education, limited economic opportunity, and poor access to health care,” she says. “All of these issues fuel poor reproductive health outcomes. In Nepal our contraceptive use rate is less than 40 percent. We also have one of the highest rates of maternal mortality in the world. One of the leading causes of maternal mortality is unsafe abortions. To address this, we are implementing a comprehensive post-abortion care program to prevent unintended pregnancies and manage complications.”
Rajbhandari is working with the Nepal Family Health Program, a consortium of four major agencies working with the U.S. Agency for International Development on a five-year program to strengthen family planning and maternal and child health. She is employed by one of the co-partners, Engenderhealth, as a reproductive health team leader.
“I provide technical assistance to the Minister of Health,” says Rajbhandari, who was a fellow at the School’s Bill and Melinda Gates Institute for Population and Reproductive Health. “Our basic job is to ensure quality of service by providing on-site coaching, giving feedback to the districts, and supervising and monitoring family planning clinics.”
Increased use of contraceptives—primarily Depo-Provera injections—has decreased the average family size in Nepal to 4.1 children per family. That’s still high by developed countries’ standards but lower than it was previously. Rajbhandari’s goal is to bring improved reproductive health benefits to all Nepalese, regardless of the terrain. “It’s a big challenge,” she says. “Right now I’m involved in writing national standards and protocols and guidelines. But the most difficult part is to implement them at a local level. You try to take these new initiatives to an outpost where there is one guy who has to do everything. Often, he’s very happy to see us. But when we begin asking for statistics and telling him about the new programs and policies—well, it can go both ways.”
On a typical day, Benedictus Ajayi will see upwards of two dozen eye patients, perhaps perform a surgery, receive reports from a rural eye hospital that he founded and directs, confer w ith students as a part-time faculty member at the University of Ibadan, and correspond with colleagues in the Ophthalmological Society of Nigeria (of which he is president). If time permits, he will give thought to the recent request from the Pan-African and Pan-Arab Conference of Ophthalmology that he help create a regional West African association of ophthalmologists to act as a conduit for training and education from international associations.
Not bad for a man who says he went into medicine by accident. “I wanted to be a chemical engineer and I had a scholarship to study in Milan,” says Ajayi, MD, MHS ’84. “But I couldn’t get a passport. So instead, I got admitted to Ibadan Medical School. On the first day, I walked into the cadaver room, took one look, and ran out. I wasn’t going to be a doctor. But still I couldn’t get a passport, so I went back.”
Today, countless West Africans owe their eyesight to this stroke of bureaucratic obstructionism. And Ajayi has found a life’s calling: fighting preventable blindness in Nigeria and neighboring countries by working tirelessly on behalf of public health ophthalmology. “A high proportion of the cases of blindness that we see are preventable,” says Ajayi. “There is cataract-caused blindness, untended trachoma, river blindness, a lot of corneal diseases, vitamin A deficiency, and measles.” To combat these and other diseases of the eye, Ajayi has long championed greater government support and an expanded body of eye-care specialists. “We don’t have enough surgeons. In a population of about 120 million we only have about 250 ophthalmologists,” he says. As a result, the backlog for cataract surgery “is very high.”
Ajayi has helped create and support innovative programs to address the problem. As a member of the faculty board of ophthalmology of the West African College of Surgeons he helped design and implement a special two-year program to train mid-level ophthalmologists to tackle common eye diseases and surgeries. He has led programs to train teachers and members of civic organizations to screen for eye disease and treat basic eye problems. And he has helped cajole the government into more outreach efforts, including regular eye camps, where large numbers of surgeries are all done at one time. “We have seen some improvement. The government is taking eye care more seriously,” he says approvingly.
When asked to list his hobbies, he puts eye camps and rural outreach at the top of his list. “If you are going to practice medicine, you must get to an area that you really love. I wanted a discipline with variety, one that would allow me to get into the field and do different things at different times.”
Clearly, for Ajayi, the eyes have it. “I am 55 now. I would like to work until about 60. I would like to strengthen the ophthalmology society of Nigeria. I want to see Internet facilities added. We need a good solid base with access to information. I want to help develop human resources, train more ophthalmologists, also make sure services meet international standards, and then, most important, I want to reduce to an appreciable extent preventable and curable blindness.”