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Good Luck Charm

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Alum Mike Zahalsky is again on the winning tribe after Survivor reassigns the contestants.

Survivors were met with a surprising order at the top of episode 4 of CBS’s Survivor: Heroes vs. Healers vs. Hustlers: everyone was told to “drop their buffs.”

It wasn’t as naughty as it sounds; the contestants were being reassigned to new tribes and received new buffs to replace the old ones. (For the uninitiated, buffs are multipurpose tubes of fabric—think headband, or tube top—which are printed with each tribe’s insignia for Survivor.)

The random tribe reassignments landed Mike Zahalsky ’95 MMS’98 MD’99 on the red Yawa tribe with two Healer teammates, plus one Hero and one Hustler. Yawa flew through their first challenge, arming them with a basket of potato chips and peanut butter and jelly sandwiches to devour while they moved to a new shelter on the beach.

Yawa’s Jessica confided in Zahalsky and Cole, her love interest, that she found a secret advantage in her bag of chips. Sticking to his strategy from episode 3, Cole promptly shared the secret with the rest of the newly formed tribe.

When the non-Healer teammates hinted to Zahalsky that someone found a secret advantage, he deftly maneuvered to gain their trust, while also disrupting the lovebirds by letting them know that someone spilled the beans.

Yawa dominated the episode’s second challenge, winning immunity from elimination. The losing Levu tribe headed to tribal council and it appeared that Zahalsky’s nemesis Joe may be voted off, but in a bizarre flurry of activity involving a secret advantage and the immunity idol, an untargeted teammate left the game. The whole Levu team was probably still perplexed at that outcome by the end of the episode.

The tribes will continue to settle in with their new teammates—and sort out this week’s unexpected ending—on next Wednesday’s episode, at 8 p.m. EST on CBS.


Never Underestimate Dr. Mike

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Showing a little grit, Mike Zahalsky finds the coveted immunity idol.

Mike Zahalsky ’95 MMS’98 MD’99, the “sex doctor” of CBS’s Survivor: Heroes vs. Healers vs. Hustlers finished episode 5 with a huge advantage and an undoubtedly proud family back home in Florida: he found one of the three prized immunity idols.

Zahalsky dug up the treasure while on a run to the Yawa tribe’s well with teammate Jessica. After looselipped teammate Cole revealed that the idol found in episode 2 was buried by the well in a previous camp, Jessica and Zahalsky opted to dig around their new water source. With idol in hand, it appears Zahalsky has a new ally.

Yawa, composed predominantly of “Healers,” continued their success in both the reward and immunity challenges. The former saw Zahalsky and teammates inch-worming on the beach to nudge a ball through a series of sandy hills, relay style. Although Zahalsky struggled with his leg of the race, supportive teammates came together to finish second, earning them a jug of iced coffee.

After a less than stellar showing in the immunity challenge, the Soko tribe headed to tribal council. A rivalry between “Healer” Roark and “Hero” Chrissy ended with Roark’s departure from the show.

Looks like there will be an unexpected medical emergency in Zahalsky’s tribe on next Wednesday’s episode, at 8 p.m. EST on CBS. Luckily, there’s a doctor in the house.

 

There’s a Doctor in the House

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Alum Mike Zahalsky brings his medical skills into play in a dramatic ‘Survivor.’

When a member of the Yawa tribe takes a sudden fall, two “Healers” jumped into action on episode 6 of CBS’s Survivor: Heroes vs. Healers vs. Hustlers.

Mike Zahalsky ’95 MMS’98 MD’99, with the help of Jessica, a nurse practitioner, shifted into professional mode, caring for a passed-out Cole and keeping the rest of the tribe calm and focused.

Between getting Cole back in the game and sharing the frutti di mare of his spearfishing labors, the Yawa tribe recognized it pays to have “Dr. Mike” on your side. This put him in stark contrast with Cole, who insisted on eating more fish than his share.

Zahalsky’s old rival, Joe, found a third immunity idol, which was perplexingly hidden in a similar fashion as the previous two—next to the well at another camp. The idol’s treasure map clue from episode 2 has proved to be a major advantage.

Yawa, with a majority of the original, challenge-dominating “Healers,” continued their winning streak, bringing home tasty pizza in the reward challenge and coming in first in the immunity challenge. Luckily for Cole, this meant safety from elimination. At least for one more week.

The losing Soko tribe trudged to tribal council for the second time in as many weeks. After casting the lone vote against a power player last week, Ali was double-crossed again (quadruple-crossed?) and voted off the island.

With the number of contestants now whittled down to 12, next week’s merging of tribes promises an every-player-for-themselves dynamic for the rest of the season. See how it unfolds next Wednesday at 8 p.m. EST on CBS.

Game Changer

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In his first tribal council on ‘Survivor,’ Dr. Mike loses his closest ally.

Nothing shakes up a season of Survivor like the long-awaited merge, where the three tribes become one and it’s every player for him or herself. On episode 7 of Heroes vs. Healers vs. Hustlers, Mike Zahalsky ’95 MMS’98 MD’99 made it to this show milestone.

In keeping with tradition, after the merge the survivors were treated to an elaborate lunch of steak, margaritas, and even molten lava cakes. The calories were a much-needed boost for the hungry players whose supplies were depleted after 16 days on the island.

But the camaraderie over cold beers had subtext. In a phone interview, Zahalsky says that post-merge, “Survivor is about making your way socially and strategically.” Players have to test the bonds of their established alliances, or reach out to find new ones. The five Yawa tribemates, including Zahalsky, went in planning to stick together.

After Desi won the first individual immunity challenge, the 12 survivors headed to tribal council―Zahalsky’s first. “My tribe had won so many challenges and never been to tribal council, which is great,” he says, “but that prevented us from playing the true game of Survivor.” In fact, Zahalsky now holds the title for most consecutive first-place wins in a three-tribe season.

At council, the Yawa tribe tried to oust hard-core player Chrissy, but were blindsided by the defection of Ben and Laura, who joined the majority to vote out Yawa’s own Jessica.

For Zahalsky, losing Jessica, a nurse practitioner who was on the original Healers tribe and who, he says, was his “biggest ally,” was a tough break. He’s undaunted, however. “It’s like figuring out how to triple concentrate at Brown and still graduate in three years [he was the first person in Brown’s history to do so]. I have to find the holes and work inside of them,” he says.

We’ll see how that goes on the next episode, Wednesday at 8 p.m. EST on CBS.

On Top of Spaghetti

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Alum Mike Zahalsky makes it to the halfway point on ‘Survivor.’

Twenty-one days on the island. Eleven survivors left. And Mike Zahalsky ’95 MMS’98 MD’99 is still standing.

The reward challenge on episode 8 of Survivor: Heroes vs. Healers vs. Hustlers randomly split the group into two teams to take turns hitting targets with a giant slingshot. The reward? A carboholic’s dream dinner of spaghetti, bread, and wine. Zahalsky’s red team got off to a strong start but fell behind when Ashley stepped to the plate and missed repeatedly. (Watching Ashley stay in the game despite obviously being in trouble was especially painful for Red Sox fans watching at home. Take her out, Grady!)

The blue team won the challenge and was whisked off to another island of Fiji for their reward. Hidden beneath the mound of pasta was a clue indicating that an immunity idol was under the team flag at camp. Once back at their island, Ryan made the first stealthy attempt to dig it up and found it, giving him an advantage he can play at a later time.

At the immunity challenge, Survivors had to balance a statue using a long pole while standing on a narrow beam. In a test of balance, strength, and mettle, Cole emerged as the winner and was safe from elimination.

The lines have been clearly drawn: the remaining Heroes and Hustlers have teamed up to take down the Healers. Tribal Council resulted in a tie, with four votes each for two of the original Healers: Joe and Desi. That necessitated a do-over, in which the other nine contestants had to choose between them. Physical therapist Desi lost the vote, but she became the first member of the all-important jury, which in the final episode will determine the Sole Survivor.

That alliance naturally has us worried for Zahalsky, but we can’t forget he still possesses the immunity idol he found in episode 5. Question is, will he play it at the right time? We’ll see next week at 8 p.m. EST on CBS.

A Question of Honor

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If you happen to have a seatbelt, now would be a good time to put it on.

Things started getting bumpy for Mike Zahalsky on Episode 9 of Survivor: Heroes vs. Healers vs. Hustlers. But first, it was reward challenge time. The castaways were randomly divided into two teams of five and had to perform a series of maneuvers then shoot balls into baskets. Zahalsky’s team won the reward: a pleasure cruise around the Fijian islands while dining on gourmet sandwiches, wine or beer, and chocolate cake.

Once back on land, the dirty business of alliances, strategy, and backstabbing was on. The alliance of seven — the “round table” — was carrying on with its plan to vote off the remaining Healers. Former Marine Ben took charge, ordering the members to split their votes for Cole and Zahalsky. That way, if a hidden immunity idol was played, they’d be assured that a Healer would be eliminated either way.

But some members bristled at Ben’s dictator-like edict, and questioned why plan B should be the affable Dr. Mike when the always-annoying Joe was ripe for picking. Lauren won the immunity idol, keeping her safe from elimination, though as one of the seven, she was presumably safe anyway.

At tribal council, things got even more interesting. Zahalsky openly questioned the alliance’s strategy, calling it immoral to leave a player in the game that everyone hates. That led to a philosophical debate about the game of Survivor. All of it was Zahalsky’s attempt to draw some fire his way, with the intention that he would then play his immunity idol, nullifying any votes that he received. In the end, just two votes were cast for him. Ultimately, Cole was eliminated, making him the second member of the jury who will choose the sole survivor.

That means Zahalsky is one of two Healers left. But will the alliance of seven hold? Find out next Wednesday at 8 p.m. EST on CBS.

The Rise and Fall of the Coconuts

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In a doubleheader, Dr. Mike’s closest ally is double-crossed.

This week we were treated to two episodes of Survivor: Heroes vs. Healers vs. Hustlers—which consequently meant two eliminations.

Episode 10 opened with the castaways discussing Mike Zahalsky ‘95 MMS’98 MD’99 playing a surprise immunity idol at tribal council. They questioned his logic, since there was no imminent plan to vote for him, and no one knew he had the idol, making it a valuable commodity in later rounds.

In his confessional, Zahalsky said he was trying to play the game his own way, and he also didn’t want to be “the idiot who goes home with an immunity idol in his pocket.” While the move perplexed his fellow Healer Joe, ultimately it solidified their alliance of two. They even created a short-lived comedy act, dubbing themselves the Coconuts—a nod to Joe’s Jamaican heritage, and to Zahalsky’s—well, he’s a urologist.

Zahalsky demonstrated his pedidexterity, nearly winning a reward challenge that involved building a puzzle with his feet. But he eventually lost to Lauren. She used her reward of a cheeseburger lunch with three castaways of her choice to completely turn the game on its head.

Long story short: the alliance of seven is over, with Joe and Mike joining with Lauren, Devon, Ashley, and Ben to oust the presumably invulnerable Chrissy, Ryan, and J.P. Ben is playing double agent, though, letting those three think he remains tight with them.

At tribal council, Ashley won immunity, teeing up the blindside nicely. While the majority thought the plan was to vote for Joe, the turncoats voted for J.P., sending him to the jury. Jaws dropped and multiple choruses of “what just happened?” followed the tribe back to camp.

On Episode 11, the rattled Chrissy and Ryan sought to make new alliances. Ryan reached out to Zahalsky, who rebuffed him, saying he had wanted to work with Ryan all along and Ryan didn’t want to. Now that Ryan needed him, Dr. Mike wasn’t going along with it.

Chrissy won the immunity challenge, keeping her safe. But the new alliance wasn’t done with blindsides. After assuring Joe and Mike that they would be voting for Ben in this super-tight alliance, they ultimately voted for Joe. Cue more looks of surprise.

And where does this leave Dr. Mike? We’ll find out next Wednesday at 8 p.m. EST.

Burn, Baby, Burn

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Alliances are in ashes after a particularly stormy episode of ‘Survivor.’

Some episodes of CBS’s Survivor: Heroes vs. Healers vs. Hustlers play out like a smooth sea, others like a dangerous ocean swell. Episode 12 was more like a hurricane for which a category has not yet been designated.

After a rehash of Joe being voted out in episode 11 (seriously, it’s been brewing for ages), the reward challenge offered a heartwarming prize: a barbeque with a loved one from home.

While every tearful reunion was touching, Mike Zahalsky ’95 MMS’98 MD’99 introducing his wife, Bari, to his competitors would have made the Grinch’s heart grow three sizes.. When Zahalsky thanked Bari for supporting him in playing Survivor―“the most selfish thing I’ve ever done,” he said―she quickly added, “This is the only selfish thing he’s ever done.” Awww.

Chrissy won the chance-based challenge and picked Zahalsky, Ashley, Lauren and Ryan­—along with their family members—for an afternoon barbecue. Being Survivor, there was a healthy dose of plotting at the reward gathering, wherein Chrissy tried to forge an anti-Ben coalition.

Back at camp, Ben encouraged the “alliance of four” (Ben, Lauren, Devon, and Ashley) to oust Chrissy, while the secret “alliance of three” (Lauren, Devon, and Ashley) debated whether Ben or Chrissy should be next to go. Meanwhile, Lauren found the first half of an immunity idol, with a note that the second half was waiting at the immunity challenge. Sound confusing? We had no idea what we were in for.

After Ashley won an immunity challenge, which stretched pain tolerance to the limit, and Lauren gathered the second half of her idol, it was back to camp to scheme.

Ben overheard the secret alliance’s plans and tried to get the remaining players (Zahalsky, Ryan, and Chrissy) to axe Lauren. But Dr. Mike had had enough of being double-crossed by Ben and immediately conveyed Ben’s no-longer-secret plan to the no-longer-secret “alliance of three.”

All pretense and diplomacy were eschewed: it was open season on Ben, Chrissy, and Lauren.

As tribal council opened the players were on edge, with alliance members taking swipes at one another. Zahalsky threw Lauren’s bridge-building idol into the fire, and chaos erupted. Players shouted, Ben declared he’s voting for Lauren, Zahalsky and Ryan openly talked shop, Chrissy and Devon ran over to whisper in Dr. Mike’s ear. It was pandemonium.

Everyone was finally ushered into the voting booth. Just as the host, Jeff, was about to read the results, Ben pulled out a secret immunity idol. Cue Jeff reading vote after vote for Ben, none of which counted due to the idol. The lone vote for Lauren was enough to eliminate her.

Be sure to rest up before next Wednesday’s episode at 8 p.m. EST on CBS.


He’s a Survivor

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Alum Mike Zahalsky heads into the finale (mostly) unscathed.

Despite the nail-biting suspense of this week’s tribal council on Survivor: Heroes vs. Healers vs. Hustlers, there’s still a doctor in the house—er, on the island—as Mike Zahalsky ’95 MMS’98 MD’99 managed to hang on.

After last week’s prime target, Ben, used an immunity idol to escape elimination, the mood at camp was edgy. Ben spent the whole episode searching for another idol as the rest of the tribe openly discussed trying to vote him out. Again.

The reward challenge saw random partners navigating an obstacle course while tethered to a rope, and while Zahalsky and Ryan put in a good showing, winners Chrissy and Devon were whisked away to a plush resort with their chosen guest, Ryan. Perplexingly, Devon accepted Chrissy and Ryan’s pitch to leave his old alliance behind and join up with his former betrayer, Ryan. Survivor comes at you fast.

Dr. Mike boosters may recall his hope of winning an immunity challenge before his time comes to a close, but this week didn’t go his way. After navigating an obstacle course, tossing balls to operate ladders, and completing a gear puzzle, Chrissy was victorious—and rapidly refocused her aim from Ben to Ashley.

Going into tribal council, it was unclear who agreed with Chrissy’s shift or whether Ben had found an immunity idol. After tribe members aired their grievances against Ben, he revealed—and played—a newly found idol, meaning he could not be voted off. With some dramatic explosion sound effects and giddy giggles, Ben literally pointed fingers at Zahalsky. Ashley and Devon seemed to be nodding along to Ben’s plan, while Chrissy and Ryan remained inscrutable.

Luckily for Dr. Mike, all but one vote was for Ashley.

Tune in next week when the season wraps with a two-hour finale, Wednesday, Dec. 20, at 8 p.m. EST on CBS.

End of the Line

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In Survivor‘s wild finale, urologist Mike Zahalsky doesn’t make the cut.

The second half of season 35 of Survivor: Heroes vs. Healers vs. Hustlers dished out ample erratic behavior, unexpected twists, and lawless tribal councils, Mike Zahalsky ’95 MMS’98 MD’99 managed to survive them all.

But the “Survivor gods” squirreled away even more surprises for Wednesday’s season finale. In addition to two more player eliminations and a chance for the final three survivors to plead their case to a jury of former tribal members, the final winner was announced in front of a live audience in Los Angeles.

After Ben, the prime target for two weeks running, slid through last week’s tribal council by the grace of a second immunity idol, his teammates opted for some shut-eye. This left Ben free to search for a third idol—his only hope for surviving another elimination. Which he did. Again.

Unaware of Ben’s success, Chrissy, Devon, and Zahalsky planned to convince Ben they’d found an idol at the reward meal. But when Ben takes the “news” of Chrissy’s “idol” surprisingly well, Devon suspected he possessed yet another #BenBomb and decided to vote for Zahalsky at tribal council.

Removing all the votes for Ben left one vote for Devon and one vote for Zahalsky. After a re-vote, the tenacious Brown alum bid farewell to Survivor as a competitor, though he did get to stick around to vote on the season’s winner.

Finally, with no more idols for Ben to find, Chrissy won a last, fiddly immunity puzzle and got a new-to-the-series secret advantage: the power to pick one person to join her as a member of the final three, with the remaining member to be determined by a fire-building challenge.

Chrissy, Devon, and Ryan all agreed that Ryan is fairly useless at challenges, so she selected Devon to challenge Ben. Despite being the camp’s de facto campfire starter, Devon was unable to start a spark in the time Ben nurtured a big, burning flame, and he once again narrowly escaped elimination.

Before a jury of their former teammates, the final three pleaded their cases to be crowned Survivor and take home the $1 million prize: Ben, as a military veteran who overcame post-traumatic stress disorder to inspire his family and fellow veterans; Chrissy, as a mom who pushed beyond her physical limits and never gave up on her dreams; and Ryan, a superfan who insists that most of the power moves that happened were indirectly due to his machinations. Some arguments were more convincing than others.

Flash-forward to a live audience and a nicely cleaned up cast along with enthusiastic families: each of the final three received at least one vote from the jury, but Ben won in a landslide—and was promptly engulfed in hugs.

Keep an eye on Brown Medicine for Zahalsky’s inside scoop on the whole season.

Martin E. Felder, MD ’52

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Martin Felder, 87, died December 31, 2017, in Carlsbad, CA. Born and raised in Fall River, MA, he graduated from Brown in 1952 and from Tufts University School of Medicine in 1956. After internship and residency in surgery at The Ohio State University he joined the US Public Health Service, completing his service as a lieutenant commander.

Martin Felder, MD, was an emeritus professor of surgery at Brown. Photo courtesy Larry Felder

Martin Felder, MD, was an emeritus professor of surgery at Brown. Photo courtesy Larry Felder

Dr. Felder started his private practice in Providence in 1963, and was instrumental in the development of Brown’s medical school. He served as chief of general surgery at The Miriam Hospital and was a member of numerous medical societies, including the New England Surgical Society. He was actively involved in medical education and was awarded the rank of emeritus professor of surgery upon retirement in 2003.

Marlene Cutitar ’83 MD’86 RES’92 trained under Dr. Felder and says that his legacy will live on at Brown. “His devotion to his family, his friends, the craft of surgery, his patients, the surgical education of medical students, surgical residents, colleagues, and The Miriam Hospital were unparalleled,” she says.

He was a Silver Life Master in duplicate bridge, a collector and connoisseur of fine wines, and an avid golfer.

Dr. Felder is survived by his wife, Velma Felder; two sons, Mark of Laveen, AZ, and Lawrence of Scottsdale, AZ; four grandchildren; and one sister.

Per his wishes, donations in Dr. Felder’s memory may be made to the public library of your choice.

Friendly Persuasion

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Patient behavior change is the key to successful outcomes.

Psychologist Mark Aloia, PhD RES’95 F’96, an associate professor of medicine at National Jewish Health in Denver, is one of a relatively small number of board-certified clinicians working in behavioral sleep medicine. Foremost a clinical researcher, Aloia has one foot in industry, where he has an unusual title: vice president and global lead, behavior change, for the medtech giant Philips.

Aloia credits a rotation in sleep medicine while at Brown with igniting his interest in obstructive sleep apnea (OSA), specifically the problem of poor adherence to the disorder’s primary treatment, CPAP (continuous positive airway pressure) therapy. Adherence to CPAP has historically been in the range of 50 to 60 percent. Aloia developed a “motivational enhancement” methodology, based on principles of motivational interviewing, and demonstrated in clinical trials that this approach boosted adherence.

His success prompted Philips Respironics, which manufactures CPAP devices, to recruit him as a clinical researcher in 2007. Aloia was on board to help the company solve this adherence problem just as it became a business problem: in 2013 Medicare began denying payment for CPAP if patients don’t meet adherence criteria. Aloia helped develop an app, DreamMapper, for Philips, and a recent study of 172,000 patients found that 78 percent of people who used the app were adherent by Medicare’s definition. Aloia notes that the app has 600,000 users; “the 22 percent improvement in adherence represents 120,000 patients who would have lost their devices,” he says.

While Aloia sees himself as a clinical researcher first, with his industry role he’s at the heart of a movement to put technology in the hands of patients to help them achieve their health goals. Too often, these fail to do the job. Lacking a basis in health psychology, apps generally use patient-sourced data to inform and educate them rather than motivating them to change. This doesn’t work for sleep apnea, he says—nor does it work in most other conditions requiring behavior change. Clinicians might make OSA patients aware that, if left untreated, their disease might lead to high blood pressure and heart failure, yet patients still don’t comply. “We, as clinicians, have often thought that if only the patients knew what we know, they would change their behavior,” Aloia says. “That doesn’t work. Even many physicians don’t adhere with their therapies.”

Aloia has codified behavioral psychology tenets into five pillars that can be described by the acronym “PAUSE” (“because software engineers asked me to fit everything that I have learned about behavior change onto one slide,” he jokes). That stands for Personalization, the need for an intervention to have personal relevance; Autonomy, meaning the patients are in control of their own choices; Urgency, the reason why the patient should change the behavior (daytime sleepiness impacting job performance, for example); Social support; and Empowerment, which comes from setting patient-specific, achievable targets along the way to major goals. “A target might be a 10 percent improvement. Reaching that … builds momentum and confidence,” he says.

This methodology might apply equally well to parenting, says Aloia, who has two boys, ages 10 and 13. But, he admits, “I don’t always practice what I preach!”

A People Without Country

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Two faculty members find themselves in the midst of the worst humanitarian crisis in the world: among the displaced Rohingya in Bangladesh.

Although the line is long with people waiting to see the doctor, there are no complaints. Headaches, fevers,
diarrhea, skin rashes—the usual primary care issues. I have participated in many of these clinics: in western Kenya, where I have worked for 20 years, and as part of the Travelers Aid medical van at home in Providence. Here, I am helping out at station no. 1, where we take height and weight. A young boy about 10 is in line and I ask through the interpreter what is his concern. He has a headache and points to a spot above his right ear. We take off his headscarf. It is a bullet wound tracing from his scalp and back across his head, and the upper part of his ear is missing. The wound is festering. That’s when I remember: this is the Rohingya camp in Kutupalong, outside of Cox’s Bazar, Bangladesh.

Origin Story

I received an email from Ruhul Abid in July 2017, asking me to attend a presentation on tuberculosis that his NGO, HAEFA (Health and Education for All), was making to the USAID mission in Bangladesh. The HAEFA project combined noncommunicable disease and tuberculosis screening efforts for factory workers and rickshaw pullers in Dhaka, Bangladesh.

Although Abid and I are both on the faculty at the Warren Alpert Medical School, our paths had never crossed until that email. Abid is in the cardiothoracic surgery department, where he studies the mechanisms to improve heart function after myocardial infarction (heart attack). I am part of the pulmonary division, concentrating on TB and the Brown Kenya Medical Exchange Program, with an office at The Miriam Hospital. The TB community is small and I wondered why I had never run into Abid previously. That email, which finally brought us together, was to take me on a remarkable journey.

A HUMAN RIGHT: Ruhul Abid founded his NGO to provide health care to factory workers and adapted that model for the Rohingya camp. Photo courtesy Ruhul Abid

A HUMAN RIGHT: Ruhul Abid founded his NGO to provide health care to factory workers and adapted that model for the Rohingya camp. Photo courtesy Ruhul Abid

In 2012, Abid saw a television report about a ready-made garment factory building in Bangladesh that collapsed and killed a large number of workers. A native of Bangladesh, with family still there, he decided to found HAEFA. Using his previous experience as a primary care physician in the tea plantations, he designed a plan to screen and link factory workers for common noncommunicable diseases: diabetes, hypertension, COPD, malnutrition, and preeclampsia. TB is also common in Bangladesh, but highly stigmatized. Abid added TB screening to his program, hypothesizing that linking TB with common diseases would reduce stigma.

Working in clothing factories in Dhaka is difficult; the emphasis is on productivity, not workers’ rights. To negotiate with employers, HAEFA had to guarantee it wouldn’t disrupt productivity levels. The entire interaction with the worker occurs within seven minutes. The HAEFA model became a series of four stations: registration; height and weight; blood pressure and finger stick for blood sugar and hemoglobin analyses; and physician examination, including TB screening questions. Information at each station is collected on an Android tablet in a prescribed format (think electronic medical record) and each patient has a unique identifier and bar-coded ID card. Patients who need followup care are linked to existing services in the community. HAEFA’s initial work in 2016, funded through the UK’s Department for International Development and Brown University’s Global Health Initiative, screened 5,776 factory workers and 1,200 rickshaw pullers in Bangladesh.

A Humanitarian Crisis

Last July the area south of Cox’s Bazar, known as Ukhiya, was mostly forestland, the hills covered by trees. But since August, 650,000 Rohingya from Myanmar have crossed over the Naf River to reach Ukhiya, and the Bangladesh government has designated the area as a campsite and has assisted in bulldozing the forest, setting up temporary shelters, building streets, providing food and water delivery, and coordinating international relief efforts.

Today the trees have been replaced by canvas and bamboo huts as far as the eye can see. The pit toilets fill within days. Water holes have been drilled in central areas. Long lines, separated by gender, await the food trucked in by relief organizations. Aid workers must leave each day at 5 p.m., when the Bangladesh army sweeps through to close the camp down, for security purposes. An informal economy has grown on the edges of the camp, selling groceries and small personal items. The roads are filled with supply trucks, as well as politicians—international and local—visiting the area.

Early in the crisis, HAEFA recognized both the need—as well as the applicability—of their model in the camp. Through Abid’s contacts in Bangladesh, HAEFA asked the offices of the Directorate General of Health Services and the regional governor to set up two medical centers in the camps. The NGO got permission to set up their camps in conjunction with the government camps. And this is how, in November, we came to be standing in the middle of the largest humanitarian crisis in the world today.

During our visit, HAEFA’s two eight-member teams had been working in the Kutupalong and Balukhali camps for just over a month. There are several medical camps, set up by the government and by multiple NGOs. The HAEFA model is much as it was in the clothing factories. Patients visit a series of stations, where health care workers record information on handheld tablets. Each patient receives a laminated ID card so that when they return, the card can be swiped for record retrieval. By the time the patient sees the physician their electronic record is populated, with a red exclamation point flagging any abnormalities. A solar panel outside the medical tent feeds the battery that runs the computers and the Wi-Fi router that connect all the tablets, for smooth synchronization of the data; each evening the data are backed up to HAEFA’s remote database. A local female health care worker fluent in both Bangla and Rohingya interprets for the doctor. Meanwhile, in the middle of the chaos, every physician takes the time to touch each patient. It’s a principle instilled by Abid: even if it’s just a finger on a pulse or a stethoscope on a chest, every physical exam employs human touch.

VIOLENT CONFLICT: Jane Carter treats a child with a gunshot wound in Bangladesh. Photo courtesy Ruhul Abid

VIOLENT CONFLICT: Jane Carter treats a child with a gunshot wound in Bangladesh. Photo courtesy Ruhul Abid

The line at HAEFA is at least five times longer than at other medical camps. The group sees 200 to 300 patients per day, working until the army closes the camp at dusk. But no one complains to us about the wait. We think HAEFA draws more patients for three reasons: they see the technology we’re using and receive a photo ID; they perceive the systematic approach to the evaluation, including blood pressure monitoring and glucose testing; and our physical exams include human touch.

These are not the best of conditions. There are overflowing pit latrines behind the HAEFA medical camp in Kutupalong. On day one of our visit, the heat and the stench were overwhelming; but the lines remained and the work went on. On day three it rained, and the water mingled with sewage and flowed down the street. In Balukhali, where the HAEFA camp is located in a valley near the base of a hill, the medical tent partially flooded. The physicians were drenched in sweat, with no place to take a break—to get a cup of coffee or glass of water. Yet the line of patients continued to move.

Sustainable Health Care

In addition to on-site treatment, HAEFA has established referral systems within the camp: for sexual violence victims, for diagnosis and treatment of TB, for safe delivery of pregnant women, for treatment of severe malnutrition, and for hospitalization for serious illnesses. Female health workers escort women identified in need by HAEFA; victims of sexual violence can be brought to woman-friendly spaces and trauma centers set up by UN agencies while pregnant women are taken to adjacent maternity and delivery centers operated by the UN Population Fund (UNFPA), and malnourished children and women are escorted to the centers run by the World Food Programme. Although all these resources exist in the camp, they were established by independent agencies and in many cases don’t effectively connect patients with the services they need.

For example, TB thrives in this type of environment; overcrowding and malnutrition drive TB epidemics. Initially HAEFA referred TB patients to the government screening center, but it turned out to be a 15-minute drive away, and none of the patients had transportation. After Abid’s visit in December, HAEFA established a collaboration with the National Tuberculosis Control Program of Bangladesh and BRAC, a Bangladesh-based NGO, for diagnosis and treatment of TB. BRAC staff members are stationed in the HAEFA camps in Kutupalong and Balukhali to collect and carry sputum of presumptive TB cases to a nearby microscopy lab. HAEFA then records the lab reports in its database—and patients don’t have to travel a long distance for sputum microscopy.

The Way Forward

As an emergency measure, the government of Bangladesh has taken on responsibility to loosely organize the camps since August 2017. HAEFA is providing care in conjunction with the Ministry of Health and Family Welfare. We saw many organizations on site—the World Food Programme, UN agencies, Doctors Without Borders, and the government of Turkey, to name a few. Major logistical challenges face the goodwill of the donors.

But what the Rohingya need is an effective health care system. In the immediate emergency response, the priority was providing the basics: food, shelter, water, safety. As time passes, the focus must shift to building the health care system—as well as providing access to jobs and schooling. Following our visit in November, we demonstrated to the UN Population Fund how HAEFA used handheld tablets to collect and organize health care records in the camps. The head of UNFPA arranged a presentation the following week to link HAEFA’s system to reproductive health care providers throughout the camp. Other caregivers also need to link their patients to the appropriate facilities. These connections are only now emerging, with HAEFA leading as a “linkage builder.”

The Bangladesh government has been doing excellent work by supplying shelter, food, and health care, including vaccines. Between 70 and 80 percent of t he people in the camps are women and children, including around 32,000 pregnant women and 100,000 children between 1 and 4 years of age. They were deprived of any systematic health care or immunizations since Burma took their citizenship away in 1982 (see sidebar). In September, after reports of polio and measles in the camps, the Bangladesh government promptly provided emergency vaccines, including cholera. But a recent outbreak of diphtheria, which infected more than 3,000 people and has already claimed 30 lives, points to the vulnerability of this population.

On the signs at the camps, the Rohingya are called “Forcibly Displaced Myanmar Nationals.” But are they Myanmar nationals? Their home country doesn’t seem to want them back. Are they refugees—never expected to return to Myanmar, but to find a new homeland? Will they be moved to an island in Bangladesh, as has been proposed, where again they will wait for political recognition and basic human rights?

These larger questions loom. For now, we are physicians. We can provide care and logistics. For now, that is the best we can provide.

HAEFA is a US-registered 501(c)3 nonprofit organization and solely dependent on fundraising to support their continued services in the Rohingya camps.

  • It’s said that “Myanmar came to the Rohingya, the Rohingya did not go to Myanmar.” The largely Muslim people has long struggled for rights and recognition in their homeland, formerly known as Burma. But historically, it was never their intention to belong to that country.

    The Rohingya are an Indo-Aryan group who are believed to have migrated from the Ganges Valley as early as 3000 BCE to the Arakan region (present-day Rakhine State in Myanmar). Difficult terrain and high mountains geographically isolated Arakan. With a mixed population of Rohingya Muslims and Rakhine Buddhists, the region remained largely independent until 1784, when Burma invaded and annexed Arakan. The British ruled the country from 1824 to 1948, and the Rohingya supported them during World War II, while Rakhine Buddhists sided with the invading Japanese forces—furthering the divide between the Rohingya and other ethnic groups in the region.

    Systematic persecution of the Rohingya began in 1978, but accelerated following the enactment of the 1982 Burma Citizenship Act by General Ne Win. This law denies citizenship to anyone who settled in Burma after 1824, when the British occupation began. Despite centuries of residence in Rakhine State, the Rohingya were stripped of their citizenship, losing their health care and other rights. Intermittent purges, from 1978 to 2017, displaced hundreds of thousands of Rohingya, with most fleeing to Bangladesh.

    The most recent exodus of 650,000 Rohingya into Bangladesh—a country the size of Iowa—was precipitated by a military crackdown in August 2017, after a militant attack on a small border station. Most of the refugees live in overcrowded camps along the border, which have sheltered Rohingya for decades. UNHCR, the UN Refugee Agency, calls this “the fastest-growing refugee emergency in the world today.”

The Good Fight

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Hepatitis C is the deadliest infectious disease in the US. The VA has a strategy to defeat it among veterans.

Homelessness, mental health disorders, and substance use can be barriers to care for patients with hepatitis C. Many state Medicaid programs, including Rhode Island’s, restrict treatment to healthy, sober individuals. But those clinical challenges aren’t stopping Veterans Administration providers in their quest to cure as many veterans with the virus as possible.

“We’ve had a veteran who came in every day to get directly observed therapy, which is something we do for tuberculosis, but we’ve never really done that for hepatitis C,” says Amanda Noska, MD, MPH, F’15, an infectious disease physician at the Providence VA Medical Center.

“That worked really well for him, and he has been cured of hepatitis C,” Noska says. “He otherwise never would have gotten treatment.”

In 2014 the VA declared war on hep C. It had 168,000 veterans in the system with the virus, and those numbers were on the rise, due not only to baby boomers who may have lived, asymptomatically, with the disease for decades, but also to injection drug use, fueled by the opioid crisis.

The agency negotiated lower prices for new, highly effective, but notoriously expensive direct-acting antivirals and has allocated more than $1 billion annually to buy them. By August 2017, the VA reports, it had treated more than 96,000 patients. The cure rate of the new drugs is about 95 percent.

“I really think we’re going to be able to wipe out hepatitis C from the VA system in the next couple of years,” says Kittichai Promrat, MD, a hepatologist at the Providence VA who heads the local arm of the nationwide initiative to treat all veterans with the virus. “They prioritize hepatitis C as an important issue that they need to address. That’s the first step. And then they allocate enough resources for us to do this type of work.”

Promrat, an associate professor of medicine, says there’s been a “paradigm shift” in the VA’s approach to hep C. Rather than wait for veterans to come to them already suffering from serious liver complications, the VA seeks them out before they get sick—with screening reminders that pop up in the electronic medical records of at-risk patients, calls and letters inviting them to come in for testing, and other outreach. As of July 2017 the VA says it had tested 79.5 percent of patients born between 1945 and 1965 and nearly 90 percent of its homeless population, two groups with the highest prevalence of hep C.

They expanded treatment capacity by allowing primary care physicians, clinical pharmacists, nurse practitioners, and physician assistants to provide care, and using telemedicine to reach more patients. “Many patients may not want to come in all the way to Providence,” Promrat says. “By having that option, it’s really helped improve treatment uptake.”

The VA’s hep C teams also collaborate with specialists in its mental health, substance use, and homeless clinics. “Many [veterans]do have issues—drug and alcohol use, mental health, homelessness—that need to be addressed at the same time,” Promrat says. “We just can’t tackle this alone.”

BOOTS ON THE GROUND

Noska, an assistant professor of medicine, sports a button on her white coat that reads, “Born 1945-1965? Ask me about Hep C!” (“I have a T-shirt too,” she says.) She sees veterans in the homeless clinic every Friday. “We’ve done a bunch of innovative things,” she says, like directly observed therapy. “It’s really very patient centered. … Just developing a really strong rapport with the patient is actually paramount to getting some of our veterans into care.”

From left, pharmacist Marlene Callahan, infectious disease physician Amanda Noska, nurse practitioner Yetunde Shittu, hepatologist Kittichai Promrat, linkage-to-care nurse Christina Furtado, and nurse practitioner Shelagh Wood-Gouveia. Photo by David DelPoio

From left, pharmacist Marlene Callahan, infectious disease physician Amanda Noska, nurse practitioner Yetunde Shittu, hepatologist Kittichai Promrat, linkage-to-care nurse Christina Furtado, and nurse practitioner Shelagh Wood-Gouveia. Photo by David DelPoio

Integrated, comprehensive treatment is easier when everything is under one roof—starting with the test. “In the conventional civilian population, you’d refer somebody to Rhode Island Hospital to get a liver elastography,” Noska says. “If they no-show that appointment, you’re dead in the water.” At the VA, she simply sends her patients downstairs. Similarly, she or Promrat might get a call from a primary care provider or social worker in another part of the hospital, and they’ll swing by to see the patient. “The VA makes it easier to coordinate and expedite care,” Noska says.

Experts who have been sounding the alarm about hep C, some for many years, say new approaches like the VA’s are the only way to defeat the disease, which kills more than 19,000 people in the US annually. “The world has the tools to prevent these deaths,” the National Academies of Sciences, Engineering, and Medicine noted in a press release last year, as it laid out a plan to get rid of viral hepatitis by 2030. But doing so requires a bold financial commitment in testing and treatment, as well as prevention measures like needle exchange—“a significant departure from the status quo.”

“We’re all supposed to be scaling up, revving up, moving faster,” says Lynn Taylor, MD RES’00 F’05, director of Rhode Island Defeats Hep C. “The VA is a bright spot in the state.”

Taylor helped establish colocated, integrated care—“one-stop shopping”—at The Miriam Hospital, where until recently she directed the HIV/Viral Hepatitis Coinfection Program; and at CODAC Behavioral Healthcare, a nonprofit treatment and recovery program in Rhode Island, where she’s now director of HIV and Viral Hepatitis Services.

But she says she can only do so much under the restrictions placed by the state’s Medicaid program. Rhode Island limits treatment to people who have reached a certain stage of advanced liver disease and who don’t use illicit drugs, and generally allows only certain specialists (usually GI and infectious disease docs) to prescribe treatment. “The evidence does not support withholding treatment,” Taylor says. “We need to identify [hepatitis C]early. … We need to get people treated and cured soon after diagnosis so they don’t get sicker … and so they aren’t spreading hep C.”

And then there are the “benefits beyond cure,” including decreased recidivism and substance use, she adds: “Patients tell us they think, ‘I’m worth it, they’re investing in me, they want my hep C cured,’ and they are motivated to work on other issues.”

Many challenges remain for the VA. Its success depends on continued Congressional allocations, identifying everyone who has the virus, and addressing the remaining barriers for those veterans who can’t get or don’t want treatment. The Providence hep C team is in regular contact with their counterparts at other VA hospitals, so they can share what’s worked and what hasn’t, and brainstorm new ideas. They’re also preparing for a certain proportion of patients who, after they’re cured of hep C, will develop fatty liver disease, Promrat says: “There’s still more work. That’s for sure.”

But for so many veterans, the VA is preventing liver cancer and liver failure and saving lives. “It’s a unique situation because I can’t think of a chronic viral disease that we can cure,” Promrat says. “This thing doesn’t come up probably again in my lifetime.”

A Hospital for the Blackstone Valley

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A resident reflects on the closing of Memorial.

At the turn of the 20th century, funded by a generous bequest from William F. Sayles, a community-based infirmary known as The Pawtucket General Hospital opened a 30-bed facility to serve the workers of the Blackstone Valley. As an “instrument of public good,” the hospital promised to treat anyone, regardless of ability to pay.

Throughout the next few decades, the renamed Memorial Hospital underwent phenomenal growth to include pediatric, maternity, emergency, surgical, and intensive care services, functioning as a comprehensive general hospital. In 1975, as hospitals across the state established a relationship with Brown University’s new medical school, Memorial became the home of the emerging and all encompassing field of family medicine.

The same year, the Division of Family Medicine established a residency program affiliated with Brown, which I am privileged to be a part of. Within the walls of the hospital and the adjoining primary care clinic, my predecessors trained in collaboration with internists and specialists to provide care across the life cycle to some of the most underserved and diverse communities in the state, including many who immigrated from Latin America, Cape Verde, and West Africa.

Despite the hospital’s growth, Memorial found a way to maintain its “small-town feel.” As trainees, it wasn’t unusual for the hospital’s telephone operator to recognize us by voice and vice versa. Across the departments, faculty came to know most trainees personally, significantly decreasing our stress level when calling a consult in the middle of the night. The stairwell between the Hodgson and Wood buildings was a common meeting place, as physicians, nurses, and staff traveled between the basement cafeteria and their respective departments.

On any given day as a family medicine resident, you could see patients in your clinic in the morning, stroll across the parking lot to “Wood 2” (the maternity care unit) at lunchtime to check on your prenatal patient’s labor progress, and then suture head lacerations on your ER rotation in the afternoon. If the stars aligned, you might run up to deliver your patient’s baby and perform a newborn exam before your drive home—all in a day’s work. This quaint, self-contained model of practice resonated with many graduates, who now comprise almost two-thirds of family medicine physicians in Rhode Island.

The closure of Memorial Hospital has a far-reaching impact on its providers and the community it serves. For many Blackstone Valley residents, this is the only hospital they have ever used, for births, deaths, and everything in between. Some employees have worked there for decades and served multiple generations of families.

As family medicine physicians, we mourn the dissolution of a full-spectrum model of care that Memorial Hospital embraced. However, the tumultuous period of change has borne opportunities to expand our presence within inpatient settings across the state, allowing for more exposure to our field and for increased interdisciplinary collaboration. And even as our patients migrate to other hospitals, we continue to care for them under our newly established inpatient services while remaining committed to providing exceptional primary care based in the Blackstone Valley.

We may no longer meet in the stairwells, but we will always carry with us the camaraderie and spirit that resonated throughout our beloved community hospital.


Dress for Success

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A doc with a flair for design launches a line of sophisticated scrubs.

A few years out of residency, Olga Lemberg MD’08 was working an overnight shift. She entered a patient’s room, introduced herself as the supervising physician, and went through her regular patient care routine. When she finished, a family member asked, “So do you know when the doctor will be stopping by? We have some questions for them.”

This is not a unique scenario. A study published in the Journal of Women’s Health found that women physicians are less likely to be addressed using their professional titles than their male colleagues, which may “amplify isolation, marginalization, and professional discomfiture expressed by women” in medicine.

More than that, for patients, “staff often blurs together from the patient’s point of view—it can be tough to tell who does what just by looking at how a person is dressed,” Lemberg says. Not to mention she just didn’t like the pajama style of scrubs.

And so Fabled was born. In July, Lemberg launched her line of fashionable scrubs that allow women physicians to not only express their personal style, but also confer an appearance of authority.

Hailed as the “Everlane of scrubs” by Racked, Vox Media’s style and shopping site, Fabled’s togs are slim-fitting and chic, not baggy and shapeless. They’re functional, too: Lemberg made sure physicians can carry everything they need, with loops and deep pockets for easy storage of keys, badges, pens, and notepads.

The two-year design process was challenging, she says. She went through dozens of prototypes before landing on a design that was just right. Sourcing fabric took over a year, because it “had to launder easily and be resistant to wrinkling, while at the same time being soft and drape well,” she says.

Trying to build a business while working as both a hospitalist and urgent care pediatrician in the Bay Area was no easy feat. A lot of late nights went into Fabled: she’d come home after a day shift and spend all night working on her designs. She says her husband joked, “You wake up thinking about scrubs and go to bed thinking about scrubs!” (Since she’s something of an expert at juggling multiple interests, Lemberg also writes a blog about work-life balance for health professionals.)

While Lemberg doesn’t have a background in business, her parents were both entrepreneurs and she credits her resourcefulness and work ethic to them. As for design, it wasn’t as much of a leap as it seems; design and medicine both require a unique and creative approach to problem solving, she says.

“A physician often faces missing information, equivocal results, or frankly the unpredictability of the human body due to its complex, dynamic nature,” she says. Design also requires this nonlinear thinking. It can involve “understanding a problem from various perspectives in order to gain new insights, testing multiple possible solutions at once, or even just allowing yourself to see a solution you weren’t expecting to see.”

Fabled is quickly gaining traction. After some prominent features in magazines like Elle Australia, demand for the designer scrubs is growing, Lemberg says. She hopes to offer more colors this spring, and add new styles by next year.

“Some of the most memorable feedback I receive revolves around customers telling me how often their patients and their patients’ families compliment them on their scrubs,” Lemberg says. “The scrubs bring my customers joy, boost morale, and give them confidence. There’s not much more rewarding than that as a designer.”

He’s a Survivor

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A longtime fan lives the dream as a castaway on his favorite reality show.

Mike Zahalsky ’95 MMS’98 MD’99 is no stranger to testing his limits. From completing three undergraduate concentrations and medical training at Brown to building a successful urology practice in southern Florida, he’s not one to shy away from difficult endeavors.

Last year Zahalsky faced his biggest challenge yet: competing for $1 million against 17 other castaways on a Fijian island on Season 35 of Survivor: Heroes vs. Healers vs. Hustlers and coming within a hair’s breadth of the win. He took a break from his post-finale Los Angeles family vacation to provide a peek behind the palm fronds.

What prompted you to audition now?
I’ve always wanted to be on the show, but for so long I had three little kids, so it would’ve been terribly selfish to go. But last year I said, “Honey, one of these days I’m going to apply,” and she laughed. … So the next day I went to my office and made a 3-minute video. I sent in, maybe, the second take, and lo and behold—boom!

How long have you been a fan of Survivor?
My wife, Bari, and I have watched Survivor since the last episode of the first season and haven’t missed one since. You know how, jokingly, everyone has a “hall pass” in their relationship? My wife’s was Ethan, the winner of Survivor Season 3, who happened to live three blocks away from us in New York City. Fast forward a few years and we named our son Ethan—I’m just glad the kid looked like me.

What about Survivor kept you and Bari watching since 2000?
I think it’s probably the best family show on television. Survivor is fascinating because there’s the physical challenge aspect that kids love and there’s a mental aspect that adults love because it cuts you to the core of who you are.

How did you prepare for the competition?
I had run a marathon in January, but I worked on agility with a trainer three days a week, throwing beanbags, tossing rings, and running balance beams to prepare for the challenges. It sounds ridiculous, but that was the stuff that I knew I would struggle with.

What was your strategy to “outwit, outplay, and outlast” before arriving in Fiji?
Don’t make immediate alliances, stay under the radar, and don’t do the first puzzle. Literally three minutes after the first marooning on the island, fellow Healer Cole comes up to me and says, “I’m really big, you’re really smart, let’s make an alliance, and by the way, Joe [long-term adversary, brief ‘coconut’ ally] is already gunning for you.” Then the puzzle comes up and I’m told: “If you don’t do the puzzle, you’re going home. If you do the puzzle and mess it up, you’re going home.”

What, if anything, about your strategy changed once you were on the island?
I went in with the “Jeff Probst approach,” leading with kindness, having justifiable ethics. I had a problem with how people were playing the middle, prompting my “Statue of Liberty speech” when I played my idol. After that, my rule became, worry about the vote in front of you. Once my outlook changed, I started playing a much different and much more successful game.

During a late-in-the-season tribal council, you told Probst that you had a “final three” in mind. Who did you want to be in the final round with you?
I had a few final threes. My wife, Bari, is also a big Survivor fan, so when she came to the island, I introduced her to everybody. I asked if I should go to the final three with Chrissy and Ryan or Ashley and Devon and she confirmed what I was thinking: Chrissy and Ryan. Devon was just such a loveable guy that he might beat me, but Chrissy and Ryan? I would’ve been so good against those two.

Why was Ben allowed to wander unattended late in the game—a move that got him two hidden immunity idols?
Two things. First, I was looking for immunity idols as much, if not more, than Ben was. Joe called me out looking for immunity idols the first week of the game, [but]it’s not like I stopped looking. At the same time, everyone is so tired that they are literally lying in the shelter all day long. If none of them are willing to leave the shelter to follow Ben, it puts me in an awkward position. I don’t want to leave and look suspicious. I have to stay as an insider, despite the risk of Ben finding an idol.

How do you feel about finishing in the final five?
It’s gonna haunt me for the rest of my life. I was planning to vote for Devon and I was setting everyone up to not be mad at me. I even told Devon to vote for me. I should’ve just worried about the vote in front of me. I practiced making fire every day—I could make fire in under a minute. Whether I would have won that last immunity or not, even making fire against Ben would have been glorious.

Wait—you told Devon to vote for you?
I did.

Oh my goodness.
I know. You have no food. You’re malnourished. You’re not thinking straight. I have reasoning behind why I didn’t vote for Devon, but does it really make entire sense? No.

As a longtime viewer, what were the biggest surprises when you were actually on the island playing the game?
The loneliness. You’re in jail and you have nobody you can trust. It’s a very pretty jail, but you’re still in jail.

What were the best parts of being on a tropical island?
Bari came out for one of the reward challenges, so she got to be a part of the experience too. We’ve been together for 16 years and we know that we were meant to be together, but going through this made us even stronger.

Were there any great stories the viewers missed due to editing?
One of the most amazing moments I had was on day 37 of 39. Things are tense, there are only 48 hours left in the game, yet the last five of us have this moment where we’re on the beach looking for an idol and I find a sea turtle nest. The babies are covered in ants and dying and we saved 22 of them that day. It was amazing. It was one of the best days of my life—despite the fact that I got voted off.

Do you have any regrets about your gameplay?
I shouldn’t have played my idol. If I hadn’t played it, an idol wouldn’t have repopulated, Ben wouldn’t have found his first idol—it would’ve been a completely different game. That said, I’m glad that Ben won. He played a great game he has a story that will help hundreds of thousands of people with PTSD.

Which cast members do you keep in touch with now that filming is over?
Would you believe it if I said all of them? We’re all in a group text. My 14-year-old daughter loves all the cute guys from the show—she’ll have me FaceTime them for her friends.

What has the reception been since you’ve gotten back to Florida?
It’s changed my life in ways you wouldn’t think. The mayor of my town had a watch party for the season finale and I’ve gotten an honor from the county. It’s incredible. People stop me in the street every day.

How has that been for you?
I love it. It’s my 15 minutes of fame and I’m going to enjoy every second of it.

Any final words to Brunonians as they bid farewell to Season 35?
I would encourage everyone to apply to Survivor. According to the website True Dork Times, Brown alums make up the most Survivor players from all the Ivies.

Read our coverage of the entire season.

Protecting Patients

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The Warren Alpert Medical School leads the country in training students to perform trauma-informed care.

DON’T: Elisseou demonstrates a traditional thyroid exam, where the physician comes from behind the patient and wraps her hands completely around the neck, which can trigger sensations of violent choking. Photo by Jared DiChiara DO: Instead, Elisseou stands within Goldberg’s line of sight, extends her fingers with her thumbs away from the neck, and explains what she’s doing and why. Photo by Jared DiChiara DON’T: To measure blood pressure, the physician stands in front of her, pressing against her knees, while the patient leans to keep her arm extended around the physician’s body. Photo by Jared DiChiara DO: Elisseou stands at Goldberg’s side and fully supports the patient’s arm under her own. Photo by Jared DiChiara DON’T: In a typical pulmonary exam, the physician stands out of the patient’s view, behind her back. Photo by Jared DiChiara DO: Elisseou stands at Goldberg’s side to perform the pulmonary exam, keeping a reassuring hand on her shoulder. Photo by Jared DiChiara

Sadie Elisseou ’06 MD’10 calls her next patient’s name into the primary care waiting room on the first floor at the Prov- idence VA Medical Center on a cold, clear morning last December. As he approaches, she greets him with a broad smile and a warm “Good morning! So great to see you.”

The patient is a burly, broad-shouldered, middle-aged man who served in Korea, Afghanistan, and Iraq and has diagnoses of depression, anxiety, a traumatic brain injury, alcohol use disorder, and symptoms of post-traumatic stress disorder. For the next 40 minutes, Elisseou, an internist at the VA and assistant professor of medicine at the Warren Alpert Medical School, takes the patient’s history, gives him a high five to congratulate his sobriety, performs a physical exam to identify the source of the persistent pain in his lower back, and works with him to develop a treatment plan that takes into account his wariness of medications and the changes in VA coverage for a massage therapist he’s found particularly effective.

Elisseou asks each question, performs each maneuver, and gives each directive with professional precision and compassion. As she explains later, she considers every aspect of the encounter an opportunity to maximize her patient’s feeling of autonomy and safety. “I am going to reach behind you to get the otoscope,” she says, while maintaining a firm hand on his shoulder to establish her presence. After discussing his options for medication, massage therapy, and yoga, Elisseou walks him to the checkout desk, thanks him, and wishes him happy holidays.

Her carefully executed patient interactions fit into a named set of practices that are gaining recognition in the medical community. In September 2017, Elisseou introduced the trauma-informed physical exam framework, upon which these exam maneuvers are based, to the MD Class of 2021. She says there have been no published reports of curricular incorporation of trauma-informed practices at other medical schools—meaning the Warren Alpert Medical School may be the first in the country to include them in an undergraduate medical curriculum.

The AFFIRM Mission

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If the federal government won’t fund gun injury prevention research, a new coalition of physicians and scientists will.

At Brown we have a strong history of practice and advocacy on behalf of vulnerable patients. Our researchers use cutting-edge theory and methodologies to reduce morbidity and mortality from a variety of preventable conditions, from opioid addiction to HIV to child abuse. We train medical students and residents in harm reduction: how to screen and counsel patients on these and other sensitive issues, to reduce risk and death. We advocate for the incorporation of evidence into policy and practice.

But there is one issue on which our profession and our school have had little impact: guns.

Approximately 38,000 Americans die each year—and another 80,000 are injured—from guns. Firearm injuries touch every segment of society, and the toll of gun deaths is similar to that of opioids or car crashes. Many of us, at and outside of Brown, have been advocating for decades for attention to this unaddressed epidemic. We have gone to Capitol Hill, written editorials, and worked within our professional societies. The reason we’ve had no impact is not a lack of rigorous research questions, nor a lack of rigorous scientific underpinnings for the field. The reason is, rather, a lack of federal funding.

Since the Dickey Amendment was passed in 1996, Congress has appropriated exactly $0 to the Centers for Disease Control and Prevention for firearm injury prevention research. The National Institutes of Health have allocated some funds to this topic, most notably in a request for applications issued after the Sandy Hook tragedy, when President Obama called for the NIH and CDC to reinvigorate their research agendas. We have had some small successes: the newly passed 2018 Omnibus Bill clarifies that the Dickey Amendment does not prohibit research, per se. The NIH currently has 14 grants focused on firearm injury prevention (I am a co-investigator on two of them).

But 14 grants is insufficient for a crisis of this magnitude. Indeed, the overall federal funding for firearm injury research remains at less than 2 percent of what would be predicted based on the mortality rate (and less than 0.2 percent of that for sepsis, a disease process with a similar mortality burden). As clinicians and researchers, we know that adequate funding is a prerequisite for high-quality research. We also know that without science, policies are unlikely to be impactful or to be based on anything other than emotion.

TIME TO ACT

Because we are tired of waiting for change, while our communities and our colleagues suffer—and because we recognize that sometimes, we need money to fix a problem—I, in conjunction with two dozen other firearm injury prevention researchers, founded the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM) earlier this year.

AFFIRM’s vision is to reduce gun injuries through knowledge and action. We want to unite clinicians and researchers across specialties, disciplines, and the 50 states to create the highest-quality, most-actionable research. Thanks to our medical society partners (including the American College of Surgeons, the American College of Emergency Physicians, and the Massachusetts Medical Society), we have the potential to not only conduct research, but also to disseminate it across the country.

The Messenger

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Philip Chan is getting the word out about PrEP.

Pre-exposure prophylaxis (PrEP) is a daily pill that prevents HIV infection and transmission with up to 99 percent effectiveness. Tens of millions of people who are at high risk for contracting the virus that causes AIDS would benefit; yet worldwide only about 200,000 people are taking the preventive antiretrovirals.

Infectious diseases physician Philip Chan, MD, MS, RES’09 F’11 treats patients with HIV and prescribes PrEP at The Miriam Hospital Immunology Center, where he’s the director of HIV/STD Testing and Prevention Services. But more and more, he’s embracing his role as communicator and educator, bringing the message of PrEP to the community and his colleagues.

“PrEP was approved by the FDA in July 2012,” says Chan, who’s also an assistant professor of medicine at the Warren Alpert Medical School. “But whether it be primary care doctors or patients, a lot of people haven’t heard about it.”

Chan spreads the word at a myriad of venues. He talks to individual patients. He helps run the Brown University AIDS Program, which trains providers, community organizations, and laypeople. He’s got undergraduate, medical, and other graduate students in the clinic. He shows up at LGBTQ events, including Pride and Trans Day of Remembrance. He sits on the boards of and collaborates with local health and outreach organizations. And he works part time for the state Department of Health as the consultant medical director for the Center for HIV, Hepatitis, STDs, and TB Epidemiology.

Community engagement has been central to Chan’s practice since he arrived in Rhode Island for his internal medicine residency in 2006, and one of the reasons he stayed. “To really make a difference in your community, you really have to be part of the community,” the Concord, NH, native says.

“Through fellowship and through residency, I’d started to make these connections.” By then he’d also grown family roots in the Ocean State: his wife, Juliette, is a Rhode Islander, and they live near her parents, in Lincoln, with their kids Aliza, 10, and Asher, 6.

Chan always wanted to follow in his doctor father’s footsteps. At the University of Vermont he earned degrees in microbiology and molecular genetics as well as medicine. But he was equally attracted to the public health aspect of HIV. “A lot of different social determinants of health intersect … things like homelessness and poverty, a lot of other comorbid diseases—substance abuse, mental health,” he says. “You can really treat the whole person, and not just the disease.”

In Rhode Island, according to research Chan conducted during his infectious diseases fellowship, gay and bisexual men account for about 70 percent of new HIV diagnoses. PrEP “really has the potential to disrupt that transmission, and really address HIV, especially among gay and bisexual men,” Chan says.

He posits that because the people most at risk are young and otherwise healthy, they’re not engaging with the health care system, so they’re less likely to learn about PrEP. But even if they do go in for a checkup, their primary care physician may not know about it, or may be reluctant to talk about sexual health. Many who are taking PrEP are proactive about their health, he says.

“We do worry that we’re not reaching the people that need it most, people who may not remember to take medicine every day, due to a multitude of reasons, whether it be mental health or substance abuse,” Chan says. “Given that those intersect with HIV risk, those are really the people that we want to get this out to.” New formulations of PrEP, including implants and long-acting injectables, are in the works.

Critics of PrEP note that it doesn’t prevent other STDs, and it could encourage risky behavior like not using condoms if people aren’t worried about HIV. “There is evidence starting to point to that,” Chan says. And rates of syphilis, chlamydia, and gonorrhea seem to be on the rise. Chan weighs those diseases, many of which are curable, against HIV, which isn’t. He also says observed increases may be due to more and better testing, which “would actually be a success.”

Rhode Island, with its small size and compact health care and research community, is the perfect place to address challenges and figure out what works, Chan says. “We have some very strong collaborations across the country,” he says. “We’re trying to set up some models here [to address HIV and STDs]that we can replicate elsewhere.”

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