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My journey into Global Health: Dr. Pragna Patel

Categories: cardiovascular disease, HIV/AIDS

Dr. Patel at her family’s clinic in India where they provide health services to indigent communities.

Dr. Patel at her family’s clinic in India where they provide health services to indigent communities.

Dr. Pragna Patel says “Taking the road less travelled and working for CDC on HIV and NCD has been a worthwhile journey”

 Dr. Pragna Patel

Dr. Pragna Patel

As a young girl growing up in New York City, I would often help out at my father’s pediatric clinic in an indigent neighborhood of the Bronx.  My father was a caring and compassionate doctor whom I truly admired and wanted emulate by providing a service to society in a meaningful way.  At that time, I never imagined that I would follow in his footsteps and become a physician. Taking the road less travelled, joining the US Public Health Service (USPHS) and working with CDC has been a circuitous, but rewarding experience and well worth the journey.
Growing up as a daughter of immigrant parents from India, I always had a desire to return to their native country, and in some way, ‘give back’.  Years later while I was a medical student, I spent two months living and working in a village in India and saw things that I never imagined possible. One day, I was standing in the operating room and my only hope in that moment was that the fly buzzing around my head would not land in the open abdomen of the patient on the table. As I stood there wearing blood-stained flip flops and gloves that had been autoclaved for re-use, I began thinking about the conditions in India and the need to improve the country’s medical care system.  Seeing a ward full of beds occupied by two people and families providing nursing care for their loved ones was very sobering for me and sparked my interest in public health.

Kenya teaching hospital

The MOI Teaching & Referral Hospital in Kenya where Dr. Patel served as the attending physician on the adult male ward during her residency.

While serving as the attending physician on the adult male ward during my residency at a clinic in the Rift Valley in Kenya, my interest in public health was deepened even further.   The average age of my patients was 35 years old and all were dying of two diseases – tuberculosis and HIV.  My medication kit consisted of four antibiotics…none of which could treat these men and save their lives.  It was during that time that I got my ’aha moment’ and realized the importance of public health practices and policies. Right there and then,  I made a conscious decision to become an Epidemic Intelligence Service Officer  and work with CDC to improve the health of populations.

Joining the USPHS and CDC and leveraging the PEPFAR InfrastructureHIV red ribbon

Since joining the USPHS  and CDC in 2002, I’ve spent 13 years working on several important public health initiatives including acute HIV screening and  characterizing the natural history of HIV in the era of effective therapy, which largely consists of  chronic diseases.  In 2013, furthering my interest in global health issues,

I accepted a position with  CDC’s Global Noncommunicable Diseases (NCD) Unit .  While my main focus is hypertension management and control, I use my HIV background considerably and leverage the PEPFAR infrastructure to provide NCD management to HIV-infected patients.</p.

Managing the ‘Silent Killer’

I am no stranger to heart disease as my paternal grandfather died after three hearts attacks at age 56 and my cousin met his demise of a massive heart attack at age 32. I know that their premature deaths were likely preventable and not uncommon.  Cardiovascular disease is the number one killer in the world and each of us is touched by it.

Worldwide, by 2025, an estimated 1.56 billion people are expected to have high blood pressure, also referred to as hypertension. Each year, hypertension is estimated to cause 9 million preventable deaths.
Risk Hypertension Infographic

Hypertension is commonly referred to as the “silent killer” because it often has no warning signs or symptoms. Many patients being treated for hypertension either do not seek medical attention or adhere to treatment regimens because they don’t have symptoms,  and are unaware that they are at risk for cardiovascular disease and can without warning, suffer a stroke or heart attack.

Although hypertension can be life-threatening, the good thing is that it is fairly easy to treat.  There are effective, affordable medications that are not difficult to take but in some settings, these medications are not widely available.

Global Standardized Hypertension Treatment Project

In recognition of the need to meet the challenge of improving the control of hypertension worldwide, CDC in collaboration with the Pan American Health Organization (PAHO), launched the Global Standardized Hypertension Treatment Project (the Project).  The Project’s goal is to improve hypertension treatment and reduce associated morbidity and mortality by developing and implementing a framework for standardizing the pharmacologic treatment of hypertension globally.  The Project proposes a Framework that includes three key elements:

    1. Using a core set of medications for the treatment and control of hypertension
    2. Increasing the availability and affordability of these medications
    3. Strengthening health care delivery systems to improve controlled hypertension at a population level and sustain long-term control for every patient
Malawi-team_600px

Dr. Pragna Patel and Dr. Sonia Angell (2nd and 3rd from Left) working with team in Malawi on an hypertension control and management project. This project will determine if standardized hypertension care and treatment that has been incorporated into existing HIV care delivery settings can lead to significant improvements in blood pressure control rates among persons with HIV and hypertension. This work has the potential to create a sustainable, feasible model for hypertension control in clinical settings throughout Malawi.

Value of the Hypertension Toolkit

The main objective of this toolkit is to provide health care providers and clinic administrators with the tools they need to improve blood pressure control among their clinic population. The materials provided include information on how to create registries to manage panels of patients and track indicators, as well as how to use standardized hypertension treatment protocols to improve the treatment and control of hypertension in clinical settings. Also included are educational materials for patients and providers as well as clinical tools for hypertension management and for improving medication adherence. The toolkit is available online at: http://www.cdc.gov/globalhealth/ncd/hypertension-toolkit.htm

These tools have been used successfully for the control of tuberculosis and for hypertension in the United States and can be leveraged for other diseases.

Partner Engagement

In low- and middle-income countries, a major challenge of controlling hypertension is medication availability and affordability.  Therefore, CDC is currently working with partners to improve access to antihypertensive medications.  For example, PAHO has included these medications on their list for the PAHO Strategic Fund to improve availability in the Latin American and Caribbean region: http://www.paho.org/hq/index.php?option=com_content&view=category&layout=blog&id=1159&Itemid=986&lang=en. The Barbados Drugs Service has done the same: http://drugservice.health.gov.bb/

While there have been many advances in electronic data collection, the technology necessary for electronic registries is not available in most low- and middle-income countries.  CDC and the Lighthouse Trust  are working with Baobab (http://baobabhealth.org/) in Malawi to develop hypertension modules to enhance local electronic medical record systems.  We hope this enhancement will be widely adopted in Malawi and will facilitate the scale-up of hypertension screening and treatment programs within the country.

Dr. Pragna Patel  team on hypertension project

Dr. Pragna Patel (front row left) with hypertension management and control team in Barbados.

CDC’s NCD Unit is also working with partners to stand up hypertension treatment programs by leveraging existing infrastructure, such as enhancing HIV care delivery at PEPFAR-funded sites to include hypertension screening, diagnosis, and treatment in Malawi.  In addition, CDC is  providing technical assistance to improve quality of care at clinical sites in Barbados, where many of the Project’s components are being implemented.  Health care institutions and other public health partners can help disseminate information about the project and engage ministries of health, academic institutions, and private organizations in adopting the components of the Project’s framework into their clinical care delivery sites.  Raising awareness about the disease and its associated complications is important as well.

For further information on the Global Standardized Hypertension Treatment Project , please contact Dr. Pragna Patel, at plp3@cdc.gov

Two Initiatives Worth Their Salt: Reducing Sodium Intake in Philadelphia and Shandong, China

Categories: cardiovascular disease, noncommunicable diseases (NCDs)

September 29 is World Heart Day.

September 29 is World Heart Day.

Background information

Barbara Bowman, Ph.D., Director, Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC

Barbara Bowman, Ph.D., Director, Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC

CDC’s 2013 Vital Signs publication reported that more than 200,000 deaths among Americans younger than age 75 are preventable. These deaths from heart disease and stroke, both primary contributors to cardiovascular disease (CVD), could be prevented through better lifestyle practices and better care. Heart disease and stroke are two of our nation’s leading causes of death, responsible for nearly 1 in 3 deaths in the US each year. Globally, hypertension accounts for almost one-half of heart attacks and strokes. In China alone, CVD caused an estimated 3.5 million deaths in 2008.

Excess sodium intake is a key risk factor for hypertension, and reducing sodium intake is a global and domestic public health priority. A 2007 study found that reducing average population sodium intake by 15% in 23 low- and middle-income countries (bearing 80% of the chronic disease burden) could prevent 8.5 million deaths over 10 years, at a cost of only $0.05 / person / year (see footnote #1). In China and in the US, average sodium consumption is in excess of recommendations (see footnote #2). Primary sources of sodium vary depending on the country: the primary sources of sodium in the US are packaged and restaurants foods, while in China it is salt added during cooking. Thus, efforts to reduce sodium consumption in each country focus on their respective primary contributors to sodium intake.

Shandong Province is the third most populous province in China with 96 million residents. Rates of hypertension and salt intake in adults are higher than the national average; Shandong Province is also one of the largest salt producers in China. To reduce the burden of hypertension, in 2011China’s National Health and Family Planning Commission (formerly the Ministry of Health) and Shandong provincial government, with technical assistance provided by US CDC, launched the first comprehensive salt reduction project in China: the Shandong Province & Ministry of Health Action on Salt and Hypertension (SMASH). The goal of SMASH is to: 1) reduce daily salt intake from 12.5 grams/day to 10 grams/day by 2015; and 2) improve hypertension control within the province.

In order to reduce salt intake, food labeling, reformulating local cuisine, distribution of scaled spoons for measurement of salt use in cooking, and food industry product reformulation are being broadly adopted. The initiative works with restaurants to develop sodium standards for Shandong cuisine, including, developing and conducting chef training and contests to provide lower salt menu items and recipes track salt usage, and disseminate educational resources. Restaurants that follow the lower salt requirement are designated a “Distinguished Restaurant”.

Philadelphia, also interested in reducing salt intake as part of its Get Healthy Philly initiative, launched the Philadelphia Healthy Chinese Take-out Initiative in 2012, a joint effort of the Philadelphia Chinese Restaurant Association, the Center for Asian Health of Temple University, the Asian Community Health Coalition and the Department of Health (DOH), to improve access to healthier food options. In an effort to control and prevent high blood pressure, the initiative aims to reduce the sodium content in Chinese take-out dishes by 10-15%. BetweenJuly, 2012 and April, 2013, 206 restaurants of more than 400 agreed to participate in the initiative. Philadelphia Healthy Chinese Take-out Initiative provided a series of free cooking trainings for owners and chefs on low salt cooking techniques. These included enhancing flavor with herbs and spices, using lower sodium ingredients such as reduced sodium soy sauce, modifying recipes to use ½ the amount of prepared sauce in dishes, and limiting distribution of soy sauce packets to customers. Marketing materials for owners and consumers to promote awareness of the initiative were also developed and distributed. DOH staff collected and analyzed samples of two popular dishes from 20 restaurants to assess changes in sodium content since the program began: preliminary results show an average of a 10% reduction in sodium content over the past two years.

After learning about US sodium reduction efforts via CDC’s Salt e-Update, SMASH officials have been working with Philadelphia Healthy Chinese Take-out Initiative to share information on their respective sodium reduction initiatives. Shandong shared CDC sodium fact sheets translated to Chinese with Philly, which assisted Philly in communicating with participating restaurant operators who only speak Chinese. Philly has provided Shandong with program insights and experience on monitoring and evaluation as well as program scope. Continued discussions will allow both communities to better communicate and share enhanced recipes, cooking techniques, and chef training materials with restaurants to reduce sodium in their menus. Expanded dialogue will also allow both projects to share lessons learned and fine tune efforts around training restaurants to reduce sodium, conducting public education campaigns focused on sodium reduction, and collecting baseline survey data to help inform targeted strategies for sodium reduction.

While the US continues to make progress in achieving our national CVD goals for sodium intake, there remains great opportunity to achieve more. Active engagement with global partners not only provides the unique opportunity to share our expertise and knowledge but to also leverage existing global efforts to enhance our knowledge and improve domestic approaches. SMASH and Philly’s Healthy Chinese Take-out Initiative share similar goals and approaches and are leveraging resources and experiences to enhance their respective programs.

To learn more:

  • CDC Division for Heart Disease and Stroke Prevention
    The mission of the Division for Heart Disease and Stroke Prevention (DHDSP) is to provide public health leadership to improve cardiovascular health for all, reduce the burden, and eliminate disparities associated with heart disease and stroke.
  • Sodium
    Most of the sodium we consume is in the form of salt, and the vast majority of sodium we consume is in processed and restaurant foods. Too much sodium can increase your blood pressure and your risk for a heart attack and stroke. Heart disease and stroke is the leading cause of death in the US.
  • Sodium Reduction Toolkit: A Global Opportunity to Reduce Population-Level Sodium Intake
    The toolkit is designed to provide international and national government agencies and public health organizations with a brief overview, tools, and information for developing and implementing sodium reduction programs, policies, and initiatives aimed at lowering sodium intake. The toolkit offers seven self-guided modules, each about 30 minutes to complete. (Chinese modules are currently hosted on a Chinese site through US CDC China office.)
  • High Blood Pressure
    High blood pressure is a common and dangerous condition. Having high blood pressure means the pressure of the blood in your blood vessels is higher than it should be. But you can take steps to control your blood pressure and lower your risk of heart disease and stroke.
  • The Shandong Province and Ministry of Health Action on Salt and Hypertension (SMASH)
  • Healthy Chinese Takeout Initiative

A Call for Action: Responding to the Tobacco Epidemic and the Price of Cigarettes

Categories: cancer, cardiovascular disease, noncommunicable diseases (NCDs), tobacco

Woman smoking tobacco

“Raising taxes to increase the price of tobacco products is the most effective means to reduce tobacco use and encourage smokers to quit.” – WHO Report on the Global Tobacco Epidemic, 2013

Samira Asma, DDS, MPH - Chief, CDC Global Tobacco Control Branch

Samira Asma, DDS, MPH - Chief, CDC Global Tobacco Control Branch

Real People, Real Stories

Mehmet Nuhoğlu started smoking when he was in middle school at the age of 12 after hearing that real men smoke. Little did he know that 45 years later his two pack a day addiction would lead to a heart attack and then cancer. “I never thought it would happen to me. I still can’t believe it,” he says.

Featured in national ads similar to the US Tips campaign, Mehmet was one of the real-life people featured in Turkey’s anti-tobacco mass media campaign that was launched in the later part of 2011. He tells of his experience with cigarettes and what daily smoking ended up costing him- his voice and his health. Now speaking with the help of an electrolarynx (a device that helps users who have lost their voice box produce clearer speech), he confesses that he regrets smoking.

March 10-16 Is World Salt Awareness Week

Categories: cardiovascular disease, noncommunicable diseases (NCDs)

 

This blog was originally posted on CNN.com on January 23, 2014.

 

Grocery store

Almost two years ago, Philadelphia launched its Healthy Chinese Take-out Initiative with the goal of reducing sodium content by 10% to 15%.

CDC Director Dr. Tom Frieden

CDC Director Dr. Tom Frieden

The city’s Public Health Department worked with 206 restaurants, first evaluating their menus for sodium content and then helping them choose ingredients and develop recipes with less sodium. One way found to reduce sodium was for restaurants to cut the use of commercially prepared sauces and instead make their own.

After nine months, the initiative analyzed two popular dishes from 20 participating restaurants to see what changed. The result? A 20% reduction in sodium, more than the project’s goal.

It’s one thing to choose how much salt to add to your food when you eat. It’s another to live with decisions made by those who prepare your food before it makes it to the table.

September 29 is World Heart Day!

Categories: cardiovascular disease, noncommunicable diseases (NCDs), women's/maternal health

 

In honor of World Heart Day, the CDC Division for Heart Disease and Stroke Prevention was asked to write commentary on the work the CDC is doing worldwide in reducing the morbidity and mortality due to cardiovascular diseases.

Barbara Bowman, Ph.D., Director, Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC

Barbara Bowman, Ph.D., Director, Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC

The theme of this year’s World Heart Day is one that touches everyone—the cardiovascular health of women and children. Though many women do not perceive cardiovascular disease (CVD) as the greatest threat to their health1, roughly 8.6 million women across the world die each year from CVD2. This is more than all cancers, tuberculosis, HIV/AIDS and malaria combined.  Women are not the only ones vulnerable to CVD. Risk among children is growing, due to increasing trends of unhealthy diet and physical inactivity. 

CVD is the leading cause of death worldwide. 

Yet there is good news: CVD can be prevented. Everyday heart-healthy behaviors, such as eating a diet low in salt, being physically active, not smoking  and promoting a smoke-free home environment, as well as avoiding the harmful use of alcohol can improve the lives of all people, no matter their age or gender. 

 
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