Stanford University
Center for Innovation in
Global Health  

Deadly Meningitis Outbreak Among Gay Men Worries Officials

The New York City outbreak has been linked to parties, online websites or apps that men used to find other men for "close or intimate sexual contact," according to health officials. But for more than half of the men sickened by meningitis, there was no evidence that the men had used any of these means to encounter other men, according to public health officials.

The specific strain linked to all the cases in New York City is part of serogroup C. It’s the same strain that first surfaced when a woman came down with meningitis in New York City back in 2003. The speed in which meningitis kills has complicated the search for people at risk.

In New York, “we’ve had several cases who have been actually found dead in their apartment before they’d even gone to see a medical provider. So that is, to us, absolutely terrifying,"  Dr. Jay Varma, the New York City Deputy Commissioner for Disease Control in the Department of Health and Mental Hygiene, told The Edge Boston in early March.

Last week, health officials in West Hollywood, Calif. warned members of the public to be alert after the death of Brett Shaad, 33, from meningitis infection. Three other cases of meningitis, including two deaths, had been identified among Los Angeles-area gay men since November.

NBCLosAngeles: Two more Southern California meningitis deaths come to light

Public health officials in Los Angeles are being careful not to cause alarm. “Right now we do not have an outbreak of meningococcal disease in LA County,” Dr. Jonathan Fielding, director of Public Health for the Los Angeles County Health Department, told NBC, citing outbreak definition requirements from the Centers for Disease Control and Prevention.  

Courtesy Shaad family via Facebo

Brett Shaad died within a week of developing symptoms of meningitis.

Shaad, an otherwise healthy lawyer, died within a week of developing symptoms. Elizabeth Ashford, a spokesperson for the family, expressed concern that the fact that Shaad was gay has been used to unfairly target him and others affected with meningitis. Allegations that Shaad was involved in any parties or other risqué activity are false, Ashford said.

“This is not a gay disease, but this is a deadly disease and that is why people should be conscientious about this disease,” she said.

Initially, meningitis symptoms may resemble the flu, with worsening headache, vomiting, and a sudden high fever (over 101.3). Over hours to days, patients develop difficulty thinking and may fall into a coma. 

Meningococcal disease, caused by the bacteriaNeisseria meningitidis, infects the lining around the brain. Once someone becomes sick, without treatment it is always fatal -- even with treatment, up to a third of patients die, Fielding said. There is a vaccine that can prevent illness, and both the Los Angeles County Department of Public Health and the New York City Department of Health and Mental Hygiene have listed clinics offering free vaccines on their websites.

Varma is concerned the outbreak is getting worse. There were a total of thirteen known cases of bacterial meningitis among men last year (triple the total in 2011). But already in the first three months of 2013, four men have been hit, not including Shaad and others in Los Angeles.

“Normally people think of an outbreak as a lot of people getting sick at one point in time – but here the number of cases is much higher than we normally expect,” said Varma.

The rate of meningitis in gay men in New York City has spiked to 60 times higher than their straight counterparts. Last fall health officials advised vaccination for some HIV-positive men, but recently expanded the recommendation to include all gay men statewide who have “traveled to the City” and “met through an online website, digital application ("app"), or at a bar or party” since September 1, 2012.

“Many people are scared,” said Anthony Fortenberry, the director of nursing at Callen-Lorde Community Health Center, which serves New York’s lesbian, gay, bisexual, and transgender communities.

Reports of a strange illness affecting gay men in two major cities may conjure images of the early years of AIDS -- as well as the stigma that surrounded patients with HIV. But experts are quick to note the differences, especially since meningitis infection can be stopped.

Dr. Mike Osterholm, the director of the University of Minnesota’s Center for Infectious Disease Research and Policy, understands the “fear factor,” but “this is very different,” he said. “With HIV/AIDS we never had the hope of eliminating it, we didn’t even know what was causing it initially. This, we know what is causing it. We have vaccines and antibiotics that can greatly reduce or eliminate carriage,” and stop the spread of the disease, Osterholm said.

At first, the meningitis outbreak in New York City seemed to infect only HIV positive men, but by March half of the men sickened were HIV negative. Three of the last five men sickened have died.

It is unclear why the current outbreak, so far, is affecting only gay men. Only two of the men knew each other and there is no evidence they infected each other, Varma said.

“Many of the outbreaks happen in settings where a lot of people live or socialize together, like college dorms or army barracks,” Osterholm said.  “When an outbreak occurs in one of these settings, health officials can track down everyone who lives in the setting, can vaccinate them and provide prophylactic medications.”

Getting the vaccine is not "outing" yourself. “It does not mean you are gay or that someone you know is gay. It is about protecting yourself,” said Fortenberry.

Osterholm agreed. “This has nothing to do with being gay,” he said.

The bacteria is spread by close contact – such as kissing, or sharing a toothbrush, a cigarette or even a coffee cup.

To date an estimated 6,700 people have been vaccinated in New York City since the start of the outbreak;1,182 people in March alone.

The Centers for Disease Control and Prevention currently recommends that children and teenagers get vaccinated but immunity wanes, leaving most adults unprotected.

Varma warns that the outbreak will likely continue until at-risk men get vaccinated. People interested in getting vaccinated can find clinics through a website run by New York City’s department of health. In Los Angeles, locations for free vaccines for the uninsured can be found here.

Kristina Krohn, MD, is an Internal Medicine and Pediatrics Resident at the University of Minnesota and the 2012-2013 Stanford NBC News Media and Global Health Fellow.


Gays in LA area warned after meningitis kills 33-year-old man


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Lost in translastion 

I wrote this article before starting this fellowship, but it is finally published. Please read the story of Kou and Hay, and think about it

Giving children a voice

The Revolutionary Optimist by Maren Grainger-Monson and Nichole Newnham deviates from standard documentaries about global poverty by showing people’s strength in changing their own communities.

Far too frequently the only way upper and middle class Americans encounter the poor of the world is through images of passive, starving people unable to help themselves used by nonprofits to ask people for money.

While it is true that poor people would love to have money it is not true that they sit their passively waiting for a hand out. Through The Revolutionary Optimist westerners follow Amlan, and some of the children he works with as they work to improve their slum.

The children in the film are inspiring – despite being born in a slum with limited opportunities, they use their brains and anything they can get their hands on to improve their circumstances. They fight sexism through co-ed soccer games, decrease polio with construction paper microphones and help families get their kids to vaccination stations.

While the film itself is inspiring, it leaves many in the audience questioning the impact of filming in the first place.  After the screening the audience asked the filmmakers a wide range of questions, but most focused on how the filmmakers interacted with the kids.

Were the kids ok with being on camera? How did the group dynamics change after they picked which kids would be followed? How did filming those individual kids change their lives? How did sharing these kids’ stories change their ability to speak up for themselves?

One project the kids started in the film was mapping their slum. It did not exist on Google maps, which left the kids feeling like the rest of the world did not acknowledge their very existence. When the kids realized they were excluded they decided to fix the map and make the government recognize that their homes existed.

Similarly, the film itself did not target certain children to make them exceptional, instead the filmmakers simply gave these kids the opportunity to use their voices unlike other organizations that take children’s images without giving the children the opportunity to share their own stories.

For more information on The Revolutionary Optimist and screenings near you check out their website.

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What to do with an ear infection?

Every parent worries about ear infections, often turning to the first line of defense: antibiotics. But according to new recommendations from the American Academy of Pediatrics (AAP) issued on Monday, doctors now say to hold off on the antibiotics for children older than six months.

"The goal is to improve the diagnosis and make sure that we preserve the healing power of antibiotics by using them judiciously in kids who benefit most. And conversely, giving kids who don't need them the opportunity to improve on their own," said Dr. Richard Rosenfeld a pediatric otolaryngologist at SUNY Downstate Medical Center.

Ear infection symptoms are the main reason doctors prescribe antibiotics to children. While every parent wants their children to feel better as quickly as possible, the AAP stresses antibiotics may not be the answer.

According to the new guidelines, children over six months old with earaches should get antibiotics if:

  • They have a history of frequent ear infections
  • Their fever is higher than 102.2
  • Their pain lasts longer than two days
  • They have a bulging ear drum 
Without these symptoms, an earache is mostly likely caused by a virus, allergies, even teething. In these cases, it is safe to put off seeing the doctor and taking antibiotics.

In these cases, the AAP encourages doctors and families to watch the child closely for improvement for 48 to 72 hours before giving antibiotics. Parents should give a child pain relievers (acetaminophen or ibuprofen based on the child?s age -- never Aspirin). If symptoms gets worse parents should not hesitate to go to their doctor.

Dr. Richard Rosenfeld, a pediatric otolaryngologist at SUNY Downstate Medical Center, says other than the common cold ear infections are the number one reason parents take their children to pediatricians. He also said the bottom line for parents is be sure your doctor is making an accurate diagnosis before they treat an ear infection, and explore the opportunity for observation as well as talking about preventive strategies.

For children with multiple ear infections, tubes implanted in the ear can help drain fluid while also allowing air into the middle ear to ward off future infections.

But what can parents do to prevent their children from getting ear infections in the first place?

  • Ensure children are up to date on their vaccines and get influenza and pneumococcal vaccines as soon as they are eligible
  • Exclusively breast feed up to six months of age
  • Avoid exposing children to tobacco smoke

Piece originally published for Nightly News, please check out that site and the accompanying video. 

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My most difficult piece so far

As a medical fellow I get to work on various different stories. One of the biggest stories I've work on so far aired on Rock Center this past week. While I mostly worked as a researcher on the piece, I also wrote the accompanying web story. So check it out by the link above.

The role of physicians in preventing gun violence.

Since the State of the Union address President Obama has hit the road to garner support for gun reform. Although the debate will continue in Washington, the president is asking individuals to step up within their communities.

Pediatricians in particular care about preventing gun violence, as guns violence kills thousands of American children each year. In response to President Obama's state of the Union and earlier statement on gun violence the American Academy of Pediatricians (AAP) "is pleased with the administration’s new national safe and responsible gun ownership campaign."  

One concern from the AAP is that laws may restrict doctors from asking patients about their gun use.

In 2011 the state of Florida passed a law preventing physicians from asking patients about guns. A federal judge blocked the law after doctors filed suit claiming the law violating physicians’ first amendment rights. 

What are the questions that cause this debate?

The standard questions I as a pediatrician ask are the following:

·         Do you have guns at home?

·         How do you store them?

·         How do you plan to introduce your children to your guns?

·         Separately I talk to the family about their child's mental health and family history.

The NRA wants to ban these questions because of concerns that the Affordable Care Act will provide means for the government to get a list of gun owners (which is explicitly forbidden by the Affordable Care Act). 


Marion Hammer, a past NRA president went even further in an article for Medscape saying that "states need to protect gun owners from overzealous doctors who ask questions simply because they want to make political statements against gun ownership." 


This seems to be a modern version of the pen versus the sword, in this case guns versus questions. 


The AAP encourages people and elected officials to support stricter gun laws, they do not encourage doctors to make political statements in the exam room. The exam room is about helping an individual or a family make the healthiest choices they can. That involves asking lots of questions, some of which can be uncomfortable.


I ask all of my families the questions above. I also ask them about bicycles, smoke detectors, car seats, lead paint, drug use and other things that hurt kids. I work with families to meet their needs, to best raise healthy kids. 


Pediatricians push more preventative medicine than many other physicians, because they care for children. That is why pediatricians recommend vaccines.


I grew up in a home with guns. I do not know if I will have guns in the home when I have children. But none of that is important when I talk to my patients. What is important is that I meet them where they are and provide them with information to make informed choices. 


Doctors ask all sorts of awkward questions. Avoiding the questions does not make the problems go away. Addressing the questions helps families make informed choices, whether that is to buy a solid gun case, get rid of the guns or how to deal with the risks of a backyard pool.


I have never had a family upset with me asking about guns in the home. And if my future patients do have a problem with me asking, you know what I'm going to do? I'm going to ask them why and try to meet them where they stand.

Why one paper cannot clear up the Myths and Truths about Obesity.

Tonight's obesity story was the hardest story I've done so far. We reported on a study entitle, "Myths, Presumptions and Facts about Obesity." I mean, how can you not report on that? With 1/3 of the United States being obese, everyone wants to know this!

I love the premise of the article. There are so many old wives tales about weight and how to lose it, but the more I looked into the article, the more problems I found.

The list of authors was impressive, all experts in the field of obesity, the journal, The New England Journal of Medicine, one of the best. As I started reading, I had no reason to be suspicious.

As an über nerd I read each myth, the studies the authors cited as the reason they could say this was untrue, and did a quick pub med search to look for other research that showed otherwise.

I was disappointed. For almost every "myth" there were articles and reviews in both directions. The one "myth" that was clearly a "myth": that sex burns a lot of exercise. I cannot verify the studies claim that sex burns on average 14 calories, but I did find studies estimating how much energy people spend with sex. For some reason no one measured it directly. But no estimate came close to burning the same amount as running for an hour, which is the "myth" the study debunked.

Several other "myths" were simply arguable. Several myths addressed rapid weight loss and the big weight loss goals. In name these are "myths"; loosing weight quickly or having a goal of loosing a lot of weight is not bad for you. The concern is in yo-yo dieting. This study did not cite the large amount of research debating this. My read: the bottom line: its probably better to lose weight and fall of track and lose it again than to stay fat all the time. But scientists still debate this. What is clear: if you can get the weight off and keep it off that is best.

The "myths" that really worried me, as a pediatrician, where the ones about kids. The authors state that neither gym class nor breast feeding prevent obesity. This is just not what I find in the literature!

There are many studies showing that gym class, especially for young kids clearly prevents their waist lines from growing out of proportion to their height and age. But studies also show that in later high school, gym class as it currently is done, simply isn't enough. There are a bunch of different programs looking at what type of gym class is enough for adolescents, and these studies show what we expect - for a healthy body you need both good exercise and a healthy diet.

And breast feeding: The World Health Organization (page 2) states that evidence shows that breast feeding babies prevents obesity later in life. This study cites a breast feeding proponent as saying breast feeding isn't as helpful as we thought it was. But when you read the entire article that the authors cite, this breast feeding proponent says in paragraph after paragraph that breast feeding helps prevent obesity.

A review of other studies shows that breast feedings protective effects against obesity although still measurable is declining. Why? Many researchers say its not that breast feeding doesn't work as well as it used too, its just that so many more people are obese now that it is harder for breast feeding alone to fight all the other reasons why we get fat.

So, if I have such problems with this study, why report on it at all? And I?m not even mentioning the financial conflicts of interests (of which there were many: food and beverage industry, pharmaceuticals, diet brands, etc.).

Initially talking with Nancy Snyderman, we were not going to. It was an interesting title, yes, but it really doesn't show anything other than that we need more definitive research.

But then it made the New York Times; people were talking. True, we could still ignore it and not be a part of the conversation. But we could also use this as a moment to remind our viewers of what we do know. And isn't the main point of news to provide people with good information to make sound decisions? If this was already in the news, shouldn?t we try to tell people what it really means?

So the story was on. But then came the real challenge: How do you make a one minute thirty second TV spot about something that just took me thirteen paragraphs to explain?

You can't include all of that, but you can try to be fair. You be the judge on whether or not we succeeded.

Bottom line: There are no quick fixes. Having a healthy weight your whole life means leading a healthy life your whole life ? a healthy diet, exercise. If something sounds too good to be true - it probably is. And researchers: keep trying to provide us real answers, my patients and I are waiting.

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Which story would you choose?

Influenza continues, norovirus outbreaks and snoring leading to heart attacks. Some days there is no specific medical headline, but what do you do when there are several?

I walked into the Nightly News morning meeting assuming we'd be doing a story about influenza as the CDC was set to announce the new national numbers later that day. We'd been emailing with producers about the ongoing severe influenza season and its timing with the winter norovirus outbreaks. But then during the morning meeting someone brought up a study that was coming out in Laryngoscope about snoring causing heart disease. With only 22 minutes of air time there wasn't room for two health stories.

In this case, each story has its own benefits and drawbacks:

Both influenza and norovirus outbreaks happen every year. Which you would think makes that old news – but because they affect people every year it is important to remind people what they can do to protect themselves.

What about snoring and that eye-catching headline that snoring might be worse for your heart than smoking? The study conclusively found that snoring thickens the walls of your carotid arteries (the biggest blood vessels taking blood from your heart to your head). This thickening is a precursor to atherosclerosis, or the plugging up of your blood vessels near your heart that leads to a heart attack. Big news: simply snoring worsens your risk of heart attacks in the future. 

But the message from this study is a little complicated: you have to describe the carotids and why the thickening is bad. And we already know that sleep apnea can lead to and worsen heart disease, and a lot of snoring is sleep apnea. 

All three stories would be worth including in the news, but which one do you choose? I already said we started the day with a planned flu/norovirus story. I had written up flu facts and was just moving on to norovirus facts when I learned we were going to do the snoring study instead. So I changed gears and got cracking on the facts around snoring. 

While I was working up the snoring story another producer came over to ask about the flu/norovirus bit, because if we didn't do it tonight, she'd produce it for the weekend segment. So I sent her what I already had for flu/norovirus and worked to finish snoring for tonight. Just as I finish the information on snoring, I learn we were tossing the snoring story and going back to flu and norovirus. 

It was well into the afternoon by this point and the show goes on at 6:30, people were out filming for both segments and yet one of them might not make the final cut. 

I flipped back and finished the science info for flu/norovirus. As I finished, I breathed a sigh of relief, but why did that story make it and not the snoring story? 

Then the producer who was going to write up the flu story for the weekend if it didn't air grabbed my attention - she was taking on the snoring story. So I got back to work finishing the information about snoring.

It is a rare day when I can't find something health related that I think should make the news. So far, most of the days I understand why one story makes the news and another doesn't. On this day -  I had no idea which story would make it. And even though flu/norovirus won out for that night, both stories actually made it on the air. 

So maybe, just maybe, I am getting the hang of figuring out what is newsworthy!

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Why Clinton's Health Matters.

As celebrities and CEOs gathered in Palm Springs for the Health Matters conference, a smaller group slipped aside to see the end product of the promises made by well to do at the conference. 

Right before the world of golf gathers amongst the luxuries of Palm Springs for the PGA Tour kicked off this week with the Humana Challenge, formerly the Bob Hope Classic, the Clinton Foundation's  calls "national thought leaders who demonstrate ways in which individuals, corporate leaders, athletes and health and wellness experts" to gather together at the yearly conference Health Matters.

I expected health insurance companies, pharmaceutical companies and medical device manufacturers but found Barbra Streisand, Jillian Michaels from The Biggest Loser, Reed Alexander who you might know from iCarly, Jen Kessy and April Ross, Olympic Silver Medalists in beach volleyball and Tom Colicchio and Lorena Garcia from Top Chef.


Why bring all of these celebrities to a health conference?

Ok, I understand Barbra Streisand. First, if you can get Barbra Streisand of course you would. Second she's donated openly to the Clinton Foundation before, and third she works with the Barbra Streisand Women's Heart Center with Ceder Sinai. 

The only demographic that doesn't know and love Barbra Streisand just might be viewers of iCarly. The celebrities cover all age groups and interest, from entertainment, to sports, to food and weight loss. But that's not the only reason this group came together.

SImilar to Barbra Streisand every single presenter at the conference advocates healthy choices. Olympians and Jillian Michaels encourage exercise. Tom Colicchio and Lorena Garcia share delicious and health food. Streisand's speech emphasized how many women suffer from heart disease compared to breast cancer.

It wasn't only celebrities from Hollywood, but also healthcare heavyweights such as a former Surgeon General of the United States, hospital CEOs and leaders from companies investing in healthcare throughout America. 

Every presenter came with specific, tangible actions they had already done to help Americans improve their health.

And its not just messages. Other presenters and attendees have created things to help people help themselves. Presenters Susan Siegel, corporate vice president of GE and CEO of GE healthymagination and  Dr. Peter Tippett, inventor of Norton Antivirus and chief medical officer and vice president of innovation for Verizon shared what their companies have done and shared future directions - note: wearable medical devices and appliances that help you with your health choices are the future.
The commitment from these large companies combined with all the start up companies and individual inventors I met in September at the MedicineX Conference at Stanford University, guarantees that every day consumers will continue to gain access to gadgets and gizmos to help them help themselves.
But the most positive part of the conference was visiting Hidden Harvest in Coachella, just outside of Palm Springs. If you look next door to many über rich enclaves you'll find America's poor barely eking out a living. 
Nancy Snyderman's story on Nightly News explains how Christy Porter started Hidden Harvest after meeting a migrant worker who was told he would be charged with robbery if he ate the fruit and vegetables left to rot in the fields after the days harvest was done. This man did not earn enough money during the harvest to buy those same fruits and vegetables in the market and was forced to watch his family starve while excess food rotted in the fields. 
Clinton made a point of visiting Coachella and thanking the volunteers. He could easily have stayed inside the gilded walls among the wealthy, but his mear presence makes a statement. Not only do we need the rich and powerful to step up and acknowledge the steps we need to improve our health, but we also need the every day Americans to step up and make it possible for everyone.
Healthy choices should not just be available to the well off, it is through the daily choices we each make that health can be attainable by all. And that is why the Clinton Foundation's Health Matters matters.

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The people who welcome you into their homes.

Before leaving the comfort of my home in Minnesota for adventures over seas, an physician advisor gave me this bit of advice, “find a cultural interpreter. Women with real experience dealing with the complexities of the culture tend to be the best.”

Initially, I did not know how to follow this advice. But as luck would have it, I ended up living with the perfect people: Madhu in India and Susan in Geneva.  These women had intimate knowledge of the culture and nothing to loose by telling me the truth. 

They also had enough authority to be comfortable telling me when I was wrong and enough connections to get me in touch with the right people.

To me, Madhu embodies the best that is India. She welcomed me into her family and prevented me from make too many cultural missteps.

Madhu’s father died while she was just a teenager. As the eldest child she dropped out of school to go to work and provide for her family.  Embracing the Indian work ethic and emphasis on family, Madhu provided for her younger brothers and sisters.  A few years later, a man at work, Mr. Sareen, asked for her hand in marriage. She had no dowry, and no father to arrange her marriage. Feeling responsible for her mother and siblings, Madhu said no, unless he agreed to help care for them. He agreed.  

In the same way that Madhu convinced her husband to care for her family, she convinced her family to care for me. I lived with Madhu, Mr. Sareen, their son, daughter-in-law and two grandchildren. 

The granddaughter taught me about their gods and goddess, while her mother or Madhu looked on. The blunt honesty of a child, sometimes explained more than I had anticipated – “How can you eat beef? That’s so cruel!” Emphasized the Hindu reverence towards cows more than the phrase “1 cow is worth 1000 gods”, which was how the Hindu view of cattle was initially explained to me. 

While traveling to the holy city of Haridwar, where the Ganges descends from the Himalayas, I followed Madhu’s advice on everything from clothing and religious respectfulness to choosing to eat vegetarian since my host ate only vegetarian.  On the last day, my host turned to me and said, “You have changed the way I think of Americans.” Thanks to Madhu I was not as greedy or materialistic as Mr. Singh anticipated, and I showed appreciation for subtleties in his culture that I would have otherwise missed.

It was with tears in my eyes that I left Madhu and her family, but I left their home to move in with Susan.

Life in Geneva revolves around the international community. Between the employees of the UN with its assorted branches, and the various international NGOs that make Geneva home you are as likely to hear English, Spanish, German, Italian, Arabic, etc. as you are to hear the official French of the Canton of Geneva. 

Susan exemplifies the international life. Born in Thailand and raised in South-East Asia and the US, she is fluent in Thai, English and French.  She also exemplifies another aspect of life in Geneva; she has dedicated her life to improving the lives of others around the world. She was even part the International Campaign to Ban Landmines that received the Nobel Peace Prize with Jody Williams in 1997.

Although I had no reason to expect anything other than a clean bed, Susan welcomed me into her life. From walking me through using the public transit system in Geneva, to long talks about the interactions of various international policies, Susan invited me into her life in Geneva as if I was living there long term rather than just a month. Arguably, I learned just as much about international relations and the culture of the UN over the dinner table as I did at work.

Madhu and Susan introduced me to local culture in a way that would have been impossible during my short time if I lived on my own. Working in global health frequently means quickly adapting to a new culture.  Both Madhu and Susan taught me how to relate to my colleagues and new people I met on the street.  

I lived in India for only 9 weeks, a very short time. But before I left several people commented, “You could almost be Indian”. From wearing sari, to appreciating religion, to family values, I was able to relate in a way many foreigners never do. 

Finding an appropriate cultural mentor is important. I lucked out with both Susan and Madhu. If someone has too much power, they cannot relate to the poor and repressed in their own culture and may intimidate the very people you want to work with. If they have to little power, they cannot help you. These strong women never led me astray.

I think of the interpreters I use in the clinic back home.  Some of the younger Hmong interpreters do not have enough power in the culture. When I ask an intrusive, personal question (for example questions about depression or thoughts of suicide) about my elderly patient, the interpreter may not interpret directly, because it is not appropriate to question their elders in such a way. 

Another example I see frequently is with my female Somali patients. If I have a male interpreter, I will not learn about any sexual complaints.  If a female Somali patient comes in because of a twisted ankle that is ok. But if she comes in for her annual exam or to talk about birth control, having a male interpreter just will not work.

Back home, my primary patients are all new arrival refugees. I wish all of my patients were as lucky as I was - that they could find people as strong and adept as Madhu and Susan at explaining the new culture they are encountering.  I am trying to learn how to fill that role to some extent for my patients. Luckily, I have good mentors such as Madhu and Susan to follow.

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