David Heller, MD, right, demonstrates blood pressure screening on Raymond Aborigo, PhD, for nursing students in Navrongo, Ghana.

Every year, the month of February is American Heart Month, a campaign to raise awareness of cardiovascular disease as the leading cause of death in the United States during a Valentine’s Day season associated with hearts and all things red. But this risk does not end in March or April—nor does it heed national borders. Diseases of the heart and blood vessels—which include not just heart attacks but also strokes— are the single leading cause of death worldwide. And the single leading risk factor for early death is high blood pressure.

The good news is that most heart disease is preventable. And even better news: You don’t need a physician to prevent heart disease. A few changes in behavior can greatly decrease risk of disease: A diet rich in fruits and vegetables, regular physical exercise, avoidance of tobacco, reduction of alcohol, and management of stress and depression. Research from around the world shows that nurses, pharmacists, and even volunteers can provide peer coaching and support to help persons at risk of heart disease to make these changes.

David Heller, MD

Unfortunately, this type of peer support is not available everywhere, either in the United States or the world. Raymond Aborigo, PhD, and I are researching care models to change that. Dr. Aborigo is Deputy Chief Health Research Officer at the Navrongo Health Research Centre (NHRC) in Ghana—a country with a massive and rising burden of heart disease, especially in recent years as diets and lifestyles have changed. With our teams at NHRC and Mount Sinai, we are exploring how best to train and equip Ghana’s health workers to treat and prevent the root causes of heart diseases through behavior change.

Ghana has a secret weapon: A nationwide rural health program that sends nurses and health volunteers door-to-door to counsel on healthy behaviors, offer basic health interventions like childhood vaccines, and link communities to essential medical care such as safe labor and delivery. This program, the Community-Based Health Planning and Services (CHPS) initiative, cut in half the number of children in Ghana dying before age 5.

Our research partnership trained the nurses of CHPS to provide door-to-door screening for two of the largest treatable risk factors for heart disease: high blood pressure and depression. We trained these nurses to treat these two conditions with medication at clinics within walking distance, and taught CHPS volunteers to visit patients at their homes weekly—offering advice on how to remember to take these medications, how to improve low mood, and other healthy habits like quitting tobacco and cutting back on salt. The team is supervised remotely by physician assistants and an on-call doctor, but nurses provide all clinical care.

In our pilot work to date, 93 percent of persons diagnosed completed our 90-day program, and 97 percent of them achieved the goal of normal blood pressure or improved depression score. We now want to scale up this program from four clinics to 20—and to adjust our care model to be as effective and easy to use for both CHPS staff members and patients alike. And because these healthy habits—including taking your medicines daily—can treat and prevent many other common chronic diseases such as diabetes and asthma, we hope to expand the model to bring comprehensive basic primary care to the people of northern Ghana and beyond.

Keeping a healthy heart is not just a one-month affair, and chronic health conditions like heart attacks cause 74 percent of all deaths worldwide. We hope to build a care model to help all people worldwide to access medications and support to prevent and control conditions like heart disease.

David Heller, MD, is an Assistant Professor at the Arnhold Institute for Global Health and the Department for Global Health and Health System Design at the Icahn School of Medicine at Mount Sinai and a practicing general internist.

Author Rose House, MD, MS, seated left, with the first class of EM Fellows in Nepal in 2014. She now works with Roshana Shrestha, MD, seated to her right, training the next generation of health care providers at Dhulikhel Hospital–Kathmandu University Hospital.

Impact. We all want to have an impact, an effect or influence on the people we meet, programs we create, or work we do. My residency program director, the late Carey Chisholm, MD, often talked of impact in the context of academic medicine: an opportunity to multiply our impact to provide excellent emergency care to many more patients and families by training the next generation of physicians.

This is the beauty of academic medicine and our academic partnership through AMPATH Nepal. Almost 10 years ago, I had the privilege of training the first class of emergency medicine fellows here in Nepal. Now those fellows are emergency medicine physicians, training the next generation of health care leaders. Roshana Shrestha, MD, is a graduate of that first class of emergency medicine fellows, a physician I would gladly have care for me or my family. I get to work alongside her in the emergency department (ED) at Dhulikhel Hospital-Kathmandu University Hospital, where she is a Professor of General Practice and Emergency Medicine. Now I get to watch Roshana teach.

Dr. House teaching alongside Dr. Shrestha and learning together during pediatric simulations.

Almost every week in the ED at Dhulikhel Hospital-Kathmandu University Hospital, Roshana and colleagues conduct in situ simulation as a part of resident training. This type of simulation takes place in the clinical setting in the ED to provide a realistic scenario for learning and practicing patient care.

We use an interdisciplinary approach to improve our teamwork, build communication skills, apply knowledge, and practice clinical skills. This is a fun and safe learning experience for the residents.

As we conduct these sessions, I admire the way Roshana and our other colleagues interact with the team—their patience, support, and teaching that fosters critical thinking. I also see the way the learners engage and respond, with deep respect, growing knowledge and skills, and a desire to learn more. I am also learning—learning how to be a better teacher, how to be a better clinician, and how to be a better team member.

Through AMPATH, we have the opportunity to do this across institutions—across continents— multiplying our impact, growing in diversity, and expanding our understanding of global healthcare needs. I get to see the next generation of physicians across our partnerships—thoughtful, committed, and talented physicians, equipped to care for our communities and train the next generation.

Rose House, MD, MS, an Associate Professor of Emergency Medicine and Pediatrics, has served as Nepal Partnership Director since September 2022. She works alongside Nepal colleagues to develop and support our global health partnership between Mount Sinai, Kathmandu University School of Medicine, and Dhulikhel Hospital in Nepal. She also provides education and clinical care in emergency medicine and pediatric emergency medicine. Before joining Mount Sinai, she worked at Indiana University School of Medicine, where she began her global health career in the AMPATH Kenya program. She then transitioned to global health work in Nepal where she supported emergency medicine training and bilateral exchange opportunities. She earned her MD at the Indiana University School of Medicine in 2005.

Rafiki Centre for Excellence in Adolescent Health, western Kenya

Adolescence is an influential period of development and a critical time for laying the foundation of good health; during this life stage, adolescents establish practices and relationships that can be protective against, or put them at risk of, poor health outcomes. To grow in good health, adolescents need age-appropriate comprehensive sexuality education, and opportunities to develop life skills in a safe and supportive environment. As well, they require accessible, appropriate, acceptable, equitable, and effective health services. This is especially the case in sub-Saharan African countries, like Kenya, where adolescents carry a higher burden of disease and face more hurdles to accessing and using health services than many of their counterparts in resource-rich contexts.

Young people in Kenya urgently need health services that are responsive to their circumstances and “adolescent-friendly” to prevent unwanted health outcomes, such as acquiring HIV, undesired pregnancy, and to support their overall mental health and well-being. Investing in adolescent health in Kenya is an investment in empowering young people to transform their communities and make vital contributions to the progress, growth, and development of nations.

The Moi Teaching and Referral Hospital (MTRH)-Rafiki Centre for Excellence in Adolescent Health, was established in 2016 in Eldoret, a city of about 475,000 people, in partnership with the Academic Model Providing Access to Healthcare (AMPATH) Kenya. The Rafiki (Swahili for “friend”) Centre is a combined adolescent medicine and research clinic that aims to become a “one-stop shop” for the provision of reproductive health, mental health, chronic disease management, HIV prevention and treatment services, and life skills for adolescents at no cost to young people in this region of western Kenya. As explained by Hilda, an adolescent peer mentor at Rafiki, “Rafiki offers the best friendly services in Kenya that accommodates all issues that we face as adolescents. Also, the staff at Rafiki value confidentiality, they are non-judgmental.”

Mount Sinai partners with AMPATH Kenya, Moi University, and Moi Teaching and Referral Hospital to advance adolescent health in western Kenya.

Currently, the Rafiki clinic primarily delivers HIV-related services, including peer support groups and educational sessions, to young people living with HIV and those who are in street situations, serving nearly 1,400 young people annually. The Director of the MTRH-Rafiki Centre for Excellence in Adolescent Health, Irene Marete, MBCHB, MMED, remarked “The health care workers in the clinic have over time bonded with the young people due to the friendly health services they offer, at the same time maintaining professionalism in their work.”

The Arnhold Institute for Global Health has established a 10-year strategic plan to grow adolescent and youth-friendly services in western Kenya. Starting with the Rafiki Centre for Excellence, efforts are ongoing to expand the existing infrastructure to provide comprehensive and integrated care to all adolescents free-of-charge, regardless of HIV, housing status, or other characteristics. Comprehensive and integrated youth-friendly services, encompasses providing holistic care across clinical specialties, including primary care, infectious disease, sexual and reproductive health, nutrition, and psychiatry, among others.

Longer term, the Institute envisions the Rafiki Centre as a “referral” point in the health system, with additional adolescent health service delivery points throughout the over 300 clinic sites in the AMPATH catchment areas. Dr. Marete envisions that “the Rafiki clinic will become a ‘one stop shop’ offering high-quality adolescent health care services—the first of its kind in Kenya.” Some young people, such as Whitney Biegon, a peer researcher at Rafiki, already consider it a full-service clinic: “One-stop shop is what comes to my mind when I think of Rafiki Centre, where adolescents and young adults can access care and treatment services, co-curricular activities as well as networking with fellow adolescents in their free time. We believe that young people are our future, hence empowering them to greater lengths is paramount under one umbrella.”

To advance this vision, there remains significant need and work to be done to ensure that the Rafiki Centre becomes the first of many places for adolescents and youth to get the care they so direly need in western Kenya free of charge. In partnership with our collaborators in Kenya, the Institute is up to the challenge and prepared to advocate, research, and lead with care to ensure young people can get the health services they need to achieve good health.

Ashley Chory, MPH, is the Global Youth Health Senior Program Manager at the Arnhold Institute for Global Health; she is responsible for overall strategic leadership for the Department and Institute’s Global Adolescent Health programs.

Lonnie Embleton, PhD, MPH, is an Assistant Professor and Adolescent Health Advisor at the Arnhold Institute for Global Health at Mount Sinai and for the Department of Global Health and Health System Design. She is responsible for conducting research addressing the health and needs of adolescents and youth, specifically underserved and marginalized people.

As global health professionals, we have a professional imperative to end systemic racism and promote justice in all the places we work and live. The attempted murder of Jacob Blake; the subsequent murders of Joseph Rosenbaum, Anthony Huber, and Breonna Taylor; and the many others who are denied justice on a daily basis are painful reminders of how little progress has been made in the United States. The disproportionate loss of even more Black lives to COVID-19 is yet another marker of the deadly impact of racism.

Ky-Shana Urie

Make no mistake—the structural racism we continue to see in America has a direct connection to the global health challenges we face abroad as well. Systemic racism is a clear global health crisis, and as global health practitioners and researchers, we have a duty to respond.

Since the murder of George Floyd in May of 2020, the Arnhold Institute for Global Health (AIGH) has engaged in an ongoing internal dialogue about race, participated in the “Chats for Change” series, hosted Rhea Boyd, MD, MPH, as a guest for our webinar series, “What Must We Do Now,” which focused on police brutality as a public health threat, and observed Juneteenth.

Madeleine Ballard

The Institute participated in both the #ShutDownSTEM protests and Scholar’s Strike for Racial Justice in June and September of 2020. Rachel Vreeman, MD, MS, Chair of Mount Sinai’s  Department of Global Health and the Arnhold Institute, is participating in Mount Sinai’s Task Force on Racism. This task force released its institutional roadmap in June 2021. At Mount Sinai, our Department and Institute have launched the decolonizing global health series in partnership with the Department of Medical Education, the Office of Diversity and Inclusion, and the Women’s Global Health Department. We have also co-led a series with Nepal Rising, Ohio State University College of Social Work, and NYC H+H/Elmhurst Hospital on COVID-19 vaccine apartheid.

In order to ensure the Department and Institute honors its commitment to combat structural racism and promote justice in our global health programs in a proactive, inclusive and transparent way, a Department-wide joint staff and faculty Task Force on Racial Justice and Equity was appointed by Dr. Vreeman, in September 2020. Our Department leadership gave the Task Force a broad mandate to review the current state of our Department and develop recommendations to strengthen our current policies and practice along with a plan of action we began implementing in January 2021.

Over the two years, the Anti-Racism Task force facilitated a participatory process by which the Department identified departmental-level problems stemming from anti-black racism; key strategies and interventions to tackle those problems; and targets for tracking progress. We have collectively identified five key areas for improvement and reckoning.

Dismantle racist incentives. Our Department identified that our evaluation rubrics incentivize, for example:

• Not “sharing the mic” (i.e. guarding authorship).
• Not committing energy to ‘non-evaluated’ efforts like diversity, equity and inclusion (DEI) initiatives.
• Focusing on journal publications, rather than other forms of knowledge, (iv) not engaging research “participants” as “co-creators”.
• Not sharing financial resources with our international partners.

We aim to dismantle racist incentives by, for example

• Counting DEI: Require all department members to have one annual review goal related to DEI (e.g. DEI-related service, engagement in learning activities etc.).
• Sharing the mic: require all research studies to have robust dissemination plans, which includes lay materials/press and community engagement with accessibly presented results.

Increase the number of Black leaders and Black faculty within the Department. We aim to do this by, for example

• Hiring fairer: increasing diversity of faculty and staff applicant pools and those hiring.
• Compensating fairer: addressing transparency in both staff and faculty salary tiers and structures during both pre- and post-recruitment.
• Increase diversity now: proactively recruit BIPOC secondary and adjunct faculty from partner organizations and internally to the Department and support their meaningful engagement with AIGH.

Improve knowledge and understanding of Black culture. Without burdening our Black colleagues with the emotional baggage of having to “educate” the rest of the Department, we want to create a work culture where all members are equipped with the tools and resources to better educate themselves about Black culture(s) and the history of racism in the United States. We also recognize that the work toward becoming a truly anti-racist department is both individual as well as collective. Therefore, everyone who wishes to participate in the process of becoming anti-racist, must proactively initiate personal steps to do so without the reliance on any one or group of individuals within the department to teach or provide information around this topic. The effort to participate in collaborative efforts to become an anti-racist department, must also be an individually initiated effort. We will work towards this goal by

• Facilitating racial healing: confront racial bias, reckon with systemic racism and engage in collective awareness generation and healing.
• Learn about Black culture: engage in this learning with colleagues, at work, together.

Cultivate humility in relation to research participants or recipients of care, most of whom are Black or people of color. We aim to work towards this, for example

• Partnering with communities: improve community engagement in research from an anti-racist perspective.
• Equipping trainees: better preparing faculty and students with whom we work to be antiracist actors.
• Ecolonizing global health: engaging deeply in the decolonize global health movement.

Improve communication. We are working towards this, by, for example

• Creating a welcoming, open, and accountable workplace. Developing a plan to instill and support interpersonal accountability and positive communication in the workplace.
• Strengthening incident reporting. Reviewing, educating, and working to cultivate trust in the incident reporting policy and practice at Mount Sinai Health System and the Icahn School of Medicine at Mount Sinai.
• Preparing all our students, faculty, and staff to be stewards of anti-racist values in our practice, communications, and collaborations and seek to remove racism, discrimination, inequity, and bias in our individual and collective voices.

The implementation of these five initiatives are being led by the Departmental nine-member anti-racism task force. Each initiative has an accompanying working group where both staff and faculty members take part.

For more information, email arnholdinstitute@mssm.edu

Ky-Shana Urie and Madeleine Ballard are Co-Chairs of the Anti-Racism Task Force