eMagazine September 2022

September 2022 Volume 45

NUVANCE HEALTH

Global Health Program

LARNER COLLEGE OF MEDICINE

NUVANCE HEALTH AND THE UNIVERSITY OF VERMONT LARNER COLLEGE OF MEDICINE

Global Health eMagazine

Be a lamp, or a lifeboat,

or a ladder. Walk out of

your house like a shepherd.

Rumi

Editor; Majid Sadigh, MD

Contributing Editor; Mitra Sadigh

Creative Director; Amanda Wallace

Cover Photo: Rose Schwartz

OUR PEOPLE,

OUR MISSION

Global Health

eMagazine

September 2022

Written by Swapnil Parve, MD

Highlights

Director of International Affairs UVMLCOM-Nuvance Health Global Health

Program

Global Health Electives in India

Highlights

Dr. Swapnil Parve, the Director of International Affairs of the Global Health Program

is currently accompanying RUSM/AUC students on their global health elective at

our partner institution Datta Meghe Institute of Medical Sciences (DU) in India.

Spotlight

Reflections

Health Disparities Within Our

Borders

Nursing Division

Among the Letters

Our Beautiful Planet

Art to Remember

Who We Can Be

Article of he Month

Videos of the Month

Global Health Family

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From left: Dr. Syed Zahiruddin Quazi (Director, Research and Development, DMIMS-DU), Dr. Abhay

Gaidhane (Dean, Jawaharlal Nehru Medical College, DMIMS-DU) and Dr. Swapnil Parve (Director of

International Affairs, NVHGHP).

RUSM and AUC students were given a warm welcome by the program coordinators

and the leadership and were placed in comfortable and safe dorms within the

campus. They started their rotations in the department of internal medicine with a

structured curriculum and after two weeks have been shifted to the departments

of their choices: surgery, OBGYN, and pediatrics.

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Left to right: Dr. Punit Fulzele, Dr. Syed Zahiruddin Quazi, Dr. Abhay Gaidhane, Dr. Wagha, Ashley

Diaz, Danielle Azani, Nistha Acharya and Dr. Swapnil Parve.


Borders

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Among the Letters


Art to Remember

Who We Can Be

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Left to right: Ashley Diaz, Nistha Acharya,

and Danielle Azani on the floors of Acharya

Vinoba Bhave Rural Hospital (ABVRH), a DMIMS

affiliate hospital.

Dr. Sourya Acharya (Head, Department of

Medicne, DMIMS-DU), and Dr. Swapnil Parve

(Director of International Affairs, NVHGHP).

During his visit to India, Dr. Parve had several meetings with the administration

of DMIMS-DU where he reacquainted the top leadership with the philosophy of

global health. A separate meeting was also held to discuss the Nuvance Health

Global Health Academy and possible role of DMIMS in fostering the south-south

collaboration.

Dr. Gaidhane, Dean of Jawaharlal Nehru Medical College and Dr. Quazi, plans

to establish a separate Global Health Office with a dedicated global health

coordinator in the near future. The Dean of the Medical College has requested

Nuvance Health to provide support in launching the longitudinal Global Health

Pathway for medical students enrolled in the General Medicine Program at

DMIMS. With appropriate guidance, they plan to launch it as early as the next

academic year. The university administration is also interested in hosting faculty

members who could deliver courses in evidence-based medicine, neglected

tropical diseases, how to teach etc.

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Highlights

During a meeting with Dr. Sourya Acharya (Head of Department of Medicine,

JNMC), as well as Dr. Shilpa Gaidhane (Section chief of Medicine ward, AVBRH),

the Director of International Affairs, learned about their needs. The department

of medicine is looking for ICU/Pulmonary Medicine specialists who could provide

courses or workshops to their residents and fellows.

Dr. Syed Zahiruddin Quazi has provided necessary assistance to the visiting medical

students to publish case reports. During a meeting with Dr. Quazi, it was discussed

how Nuvance Health Global Health Program can support research at DMIMS as

well as the role of their Research House in helping other global health partners

through various means, including but not limited to, delivering workshops, faculty

development programs etc.

The DMIMS leadership has reassured their full support for the Global Health

partnership between Nuvance Health and DMIMS.

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Among the Letters


Art to Remember

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The UVMLCOM Global Health

Leadership in Uganda

Written by Susan Byekwaso

Coordinator of the International Office at

MckCHS

SARS-CoV2 dropped a wall between nations

and pushed global health education

programs into hibernation. Although the

University of Vermont and Makerere University

College of Health Sciences continued to work

together virtually, there was still something

missing: physical meetings, eating together,

hugging, and eye contact.

After several months of planning, four rising second-year medical students arrived

in Uganda, accompanied by two faculty from University of Vermont to help

them settle into their new learning environment, for a global health education

placement. To renew commitment with MakCHS, the faculty met with several

people in administration.

The first meeting was with the Head of the Department of Pediatrics together

with the Students’ Training Coordinator, Associate Professor Nicolette Nabukera.

Participants from MakCHS expressed desire to work with the University of Vermont

Department of Pediatrics in areas of graduate students and staff training as well

as capacity enhancement and research. The Department has over 70 graduate

students and has sub-specialty training programmes for fellowships including

hematology and Neonatology.

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Dr. Andrea Green, Dr. Mariah McNamara and Dr. Sabrina Bakeera

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Dr. Andrea Green expressed gratitude to the pediatricians for hosting the meeting.

She informed members that she works as a pediatrician and the Director of

Academics and her focus is on settling refugees in Vermont. UVMLCOM has a small

residency program in pediatrics, with only seven new residents accepted annually.

On areas of future collaboration, members agreed that they should embed

psychology, social workers, nutrition, autism, cerebral palsy, patient advocacy, and

neonatology.

Dr. Andrea Green welcomed the idea of hosting pediatric residents and fellows for

one month of observation and including the faculty from MakCHS to participate in

training of students in person or virtually at UVMLCOM.

During this meeting, multiple other potential collaborative projects including

reviewing the pediatric department’s curriculum to include social determinants

of health were also discussed. Following the meeting, the team joined Associate

Professor Nicolette Nabukeera on a pediatric ward round and Malnutrition Unit. At

the end of the visit, Dr. Sabrina presented her recently published book titled Real

Pursuit of Excellence as a gift to Dr. Mariah McNamara and Dr. Andrea Green.

UVMLCOM leadership also had separate meetings with the Head of the Psychiatry

Department, Professor Noeline Nakasujja and made a trip to Nakaseke and

Naggalama to meet with the leadership of ACCESS and St. Francis Hospital,

respectively.

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Bath time (Rose Schwartz)

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Spotlight

Bemen Habashi, MD

Dr. Habashi graduated from Ain Shams

University Faculty of Medicine in Cairo, Egypt.

He worked as a primary care physician in

Egypt and Doctors of the World in NYC,

then joined Yale School of Medicine as an

Associate Research Scientist. He completed

his internal medicine residency training at

Yale-Waterbury Internal Medicine Residency

Program. He subsequently joined the faculty

of the Yale-Waterbury Internal Medicine

Residency Program as a Clinician Educator.

Dr. Habashi has a special interest in Global

Medicine and Point of Care Ultrasound. He

is currently pursuing MSs in Epidemiology

at London School of Hygiene and Tropical

Medicine, the Distance Learning program.

He enjoys hiking, playing soccer, and skiing.

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Dr. Bemen Habashi with Susan Byekwaso in Kampala, Uganda

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Mzungu Learns from Uganda

Written by Bemen Habashi, MD

Clinical Educator at the Yale-Waterbury Internal Medicine Residency Program

The Luganda word Mzungu means “white.” You hear it a lot while walking in the

streets. Though some may initially think it is a racist word, seeing children shout it

happily gives a feeling of welcoming from the community. It is a good word from a

Luganda standpoint. One should like to be a Mzungu in Uganda.

While buying a water bottle from a convenience store near the hospital, a middleaged

man asked one of the students, “Why are you here in this hospital?” The

student introduced himself and explained that he is here to learn. The middleaged

man sarcastically asked how a Mzungu could learn from Uganda.

I was proud of this medical student’s response, expressing his intention to adopt

some of what he learned into his practice on returning home. It was a surprising

answer given the false and misguided narrative that medical students participate

in global health electives to “help” host communities. There will always be an

opportunity for each of us to show respect and appreciation for what we have

gained and continue to gain as resource-rich communities. It is time to give back

and acknowledge the contribution of resource-limited communities to our learning.

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A perfect summer day. Lake Andrews. Bates College. Lewiston Maine (Dr. Stephen Scholand)

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My Global Health Roots – From the

Larner School of Medicine Towards

the Future

Written by Omkar Betageri, MD

UVMLCOM alumnus

As an extension of my interest in global health,

my experience with the Chagas Research

Team through the University of Florida has

been one of my most memorable experiences

during residency training. It has been a

remarkable opportunity to be a part of an

initiative providing migrant farmworkers with fundamental healthcare screening

for diabetes and hypertension, as well as focused screening for Chagas Disease.

It has helped me gain first-hand experience conducting screening EKGs and

play a leadership role in counseling patients with conduction abnormalities to

seek follow-up care.

As a first-generation Indian American traveling to rural areas of India at a young

age, I developed a curiosity in the discrepancies in medical care in resourcelimited

settings. Prior to medical school, I worked as a clinical research associate at

a community hospital in a low-income area of Bridgeport, CT, helping coordinate

free health screenings for breast, cervical, and colon cancer, connecting hundreds

to thousands of individuals with access to USPSTF recommended screenings.

Soon thereafter during medical school at the Larner College of Medicine at the

University of Vermont, I was chosen to participate in a Global Health elective

where I traveled to Parirenyatwa Hospital in Harare, Zimbabwe during my first

year and Makerere University Hospital in Kampala, Uganda during my fourth year.

These experiences during medical school became far more than isolated learning

opportunities– the patients and their stories have served as the backbone of

my continued interest in Global Health and the care of the underserved. One

particular patient was a 16-year-old girl with end-stage rheumatic heart

disease, who simply did not have access to penicillin therapy after contracting

“Strep throat” as a child. She had been re-admitted with decompensated heart

failure, yet another admission during the previous several months. I rounded on

her bedside during her several week long battle against her illness, and ultimately

due to the lack of access to necessary cardiac and surgical care, she succumbed

to her disease. Stories such as hers stay with me today and are part of the

foundation behind why I want to continue my efforts to serve the underserved,

both in our country and abroad.

My excellent internal medicine training at the University of Florida has equipped

me with a dynamic skill set, as I led multidisciplinary teams in caring for

uninsured individuals as well as those with low medical literacy in the inpatient

and outpatient settings. Moving forward, I am excited to begin my cardiology

fellowship training at Maine Medical Center, an institution which shares my

passion for Global Health. The program features a Global Health elective in

which fellows travel with an attending cardiologist to Rwanda to participate

in Team Heart- a multinational, multidisciplinary team caring for patients with

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operative and nonoperative rheumatic heart disease. I hope to participate in this

excellent opportunity to further my knowledge of cardiovascular Global Health.

Overall, my cardiology subspecialty interests involve interventional cardiology and

cardiac critical care, which I plan to integrate into Global Health-related medical

care. I look forward to continuing to build my clinical and scholarly skills during

my cardiovascular training to ultimately have a meaningful impact on the lives of

patients.


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(Rose Schwartz)

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To Practice Medicine In A Place

That Was So Foreign Yet So familiar

Written by Melissa Alvarez, MD

Cardiovascular Disease Fellow, PGY-V

Danbury Hospital


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Havana is a place I’ve been hearing about

my entire life. Both my parents were born in

Cuba, and my father was raised in downtown

Havana. Growing up I heard so many stories

about the island from my relatives, but it was

a place I never thought I would get the opportunity to visit. I had also heard a lot

about Cuba from the media, movies, and documentaries—everyone knows Cuba

is the home of classic cars, good rum, and healthcare for all.

Cuba’s healthcare system is usually described in a positive light. Every citizen

has healthcare, which means people in Cuba do not face the same challenges

as people in the United States in terms of healthcare costs. At the same time, this

does not mean that all citizens have equal access. The hospitals face serious

challenges with lack of access to medicines, equipment, and cardiac devices.

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Outside of my father’s childhood home

Outside the hospital we were working at

with Dr. Jarrett

During my time at a dedicated cardiovascular hospital in the capital city, dozens

of patients were awaiting pacemaker placement due to supply shortage, and

there was lack of access to Plavix, a key medication for patients who have a

heart attack. I wonder about the challenges rural hospitals face.

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What impressed me most is the strength and resilience of Cuban physicians

and trainees. It is apparent that despite feeling frustrated about the limitations

in providing the best possible care, they still did the best they could and were

extremely knowledgeable. We held case discussions, question-and-answer

sessions, made rounds together, and scrubbed into surgeries together.

Exploring the streets of Havana with my Cuban colleagues was also an amazing

part of the journey. I cannot say enough about the amazing hospitality of everyone

we met during our stay. Walking the same streets that my father walked as a child

was emotional and eye-opening. I even had the opportunity to visit his childhood

home—a memory I will never forget.

Practicing medicine in a place that was so foreign yet so familiar was the experience

of a lifetime. I connected with my roots more deeply, met incredible physicians

who taught me so much, and became more aware of the plurality of healthcare

systems. Thank you to everyone who makes “Hearts Around the World” possible!

You are impacting so many lives in such an amazing way.

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Hearts Around the World participants

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Reflections

Lessons Learned from

Ugandan Women

Written by Joanna Pierce

UVMLCOM Class of 2025

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My previous travels to Uganda and

other countries helped ease the

inevitable culture shock on arriving

here. I had an idea of Ugandan culture

and what to expect. I was familiar with

boda-bodas and the taxi system. I

had eaten my fair share of matoke and

had experienced the excitement and beauty of visiting public markets. But as a

female medical student, I have struggled with aspects of Ugandan gender roles.

Early on I noticed subtleties such as being referred to as a nurse or nursing student

while my male colleague was always given the title of “doctor”— something I have

also experienced at home in the United States but still gets to me every now

and then. As time went on, I was increasingly asked about my marital status and

how many kids I have. I expected this topic to come up given the importance

of raising a family in Ugandan

culture, but I was not prepared

for some of the responses.

When I tell people I do not have

children, I often receive followup

questions or comments that

are difficult to hear.


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Joanna with the medical team

This past week has been

particularly challenging with

the attention and questions

coming from some of the male

doctors. It has become clear

that we do not agree on the

capabilities and roles of female

doctors—a reality that has been

frustrating and discouraging at

times, however has also led to

great exchanges of ideas and

mutual learning. As a result, I

have sought out people who

want to teach me: outpatient

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clinicians and the radiology technician who are passionate about their work and

have helped me learn about aspects of medicine that are less familiar to me.

Meeting so many impressive female doctors here in Uganda has been very

meaningful. This evening, for instance, I spoke with a female pediatric oncologist

who joined us for dinner at the Luboga’s home. She shared similar encounters she

had as a medical student and as a young doctor. It was encouraging to hear how

she responded and ultimately excelled, securing her spot as one of only a few

pediatric oncologists in all of Uganda. Knowing that she and other female doctors

have endured similar challenges gives me reassurance and encouragement to

finish the last week in a more positive light. Encountering these biases and speaking

with women who have overcome them have helped me feel better prepared to

navigate similar situations at home.

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(Elina Mukhametshina)

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The hospitality and kindness

of the people at Datta Meghe

Institute of Medical Sciences

Global Health

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Written by Nistha Acharya

RUSM, Class of 2023

I have been very impressed with the

hospitality and kindness of the people

at Datta Meghe Institute of Medical

Sciences. From the cafeteria staff to

the hospital attendings, I am grateful

to the many individuals that have gone

out of their way to accommodate us. On day one we were picked up by Priyanka

who has been an excellent resource to us during our first week. She was technically

our first impression of India and I was taken with how friendly and helpful she was.

Talking to her felt like I had known her for much longer than I actually did, which

is a trait I am realizing is a commonality for the people of Sawangi. They really do

make you feel like family.

There is definitely a greater emphasis placed on physical exams compared to the

States, likely due in part to more thorough medical knowledge as well as scarcity

and medical expenses for the patient that comes with more labs and imaging.

For example, we were told to palpate the doughy consistency of the abdomen of

a patient with miliary tuberculosis.

It was shocking to realize just how far patients travel to be seen at this hospital.

One patient traveled over six hours. This is a stark contrast from the healthcare

access we have in the United States. I have observed doctors here are treated

with a greater amount of respect than back home and patients/other hospital

staff definitely put them on a pedestal. Workdays are six weeks here in India so

we are expected to be at the hospital on Saturdays, and residents work seven

days a week. I am unaware if attendings also work seven days a week, as there

are fewer attendings at this hospital compared to the patient count.

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Health Disparities

Within Our Borders

Section Editor: Ritesh Vidhun

Undergraduate junior at Tufts University

studying public health and economics on the

pre-medical track

Written by Ritesh Vidhun

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Skip a Meal for Your Meds? The

Increasingly Detrimental Situation

of Pharmaceutical Drug Costs in the

United States

Part 2/2

Imaculada Hernandez, PharmD, PhD, assistant professor at the University of

Pittsburgh School of Pharmacy, found that in the case of brand-name drugs, rising

prices were driven by manufacturers increasing prices of medications that are

already in the market rather than [by] the entry of new products,” (Hernandez in

Blumberg 2019). For example, a brand of insulin called Lantus increased in price by

almost 50 percent despite being on the market for over a decade. Yet the average

net price for Lantus has actually decreased in recent years. Pharmaceutical drug

manufacturers are increasing the prices of essential drugs, not only because of

research and development costs but also the freedom and lack of competition

that exists in the American market. These developments have large ramifications

on all individuals, not only those who are uninsured. Hernandez explains how

“rising drug prices affect uninsured or underinsured patients, patients with highdeductible

plans, those in the deductible or doughnut hole phase of their plans,

the government as a payer, and all Americans in the form of higher premiums”

(Blumberg 2019). There exists a series of problems that arise from increasing drug

costs which impact a much larger spectrum of people than one may assume. This

issue causes many Americans to avoid taking their much-needed medications

due to financial reasons. In fact, a KFF study discovered that uninsured individuals

are nearly three times as likely to skip their prescription due to cost (Lopes 2019).

Furthermore, even “14 percent of insured Americans reported that, in the past year,

they did not fill a prescription or skipped doses of medicine because of the cost,

2 percent in the U.K. and 10 percent in Canada, the nation with the highest rate

after the U.S.” (Sarnak et al. 2017). The financial burden of pharmaceutical drugs

has reached a point where people have to skip their treatments and suffer through

illnesses because of financial restrictions.

It is clear that increasing drug costs is an issue that severely impacts many

Americans and one that needs to be solved immediately. It has tremendous effects

on U.S. healthcare and prevents many from obtaining the medications that they so

desperately need. Whether you have insurance or not, the rising costs of medications

negatively affect everyone. Being able to understand the developments that have

led to this situation is necessary before considering possible solutions to gain a

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wider perspective. This problem can be very complex and being aware provides

people with the opportunity to understand why their out-of-pocket spending is

so high and how the government is (or is not) helping them. Although this problem

is one that many lawmakers are hoping to tackle, the partisan political gridlock

in Washington has made it difficult to pass much meaningful legislation. Until our

elected officials decide to work across the aisle and focus on the people rather

than their political parties, it is certain that there will be little change to come. That

is why it is necessary for more individuals to become informed about the current

state of the pharmaceutical drug situation. Greater awareness will eventually

lead to more involvement and activism, consequently helping demonstrate to the

government the importance of finding a solution. The shocking costs of drugs in

the U.S. are so much higher than other developed nations, preventing our citizens

from receiving effective care and services. Understanding and tackling this major

issue will help propel the U.S into eventually improving the standard of living for

all. As change remains on the backburners of American society, it is only a matter

of time until problems become irreversible.

References:

4: Hernandez, Inmaculada, et al. “The Contribution Of New Product Entry Versus

Existing Product Inflation In The Rising Costs Of Drugs.” Health Affairs, vol. 38, no.

1, Jan. 2019, pp. 76–83. DOI.org (Crossref), doi:10.1377/hlthaff.2018.05147.

5: Blumberg, Yoni. “Here’s Why Many Prescription Drugs in the US Cost so Much—

and It’s Not Innovation or Improvement.” CNBC, 14 Jan. 2019,

https://www.cnbc.com/2019/01/10/why-prescription-drugs-in-the-us-cost-somuch.html

6: Sarnak, Dana O., et al. Prescription Drug Spending: Why Is the U.S. an Outlier?

Oct. 2017.

https://www.commonwealthfund.org/publications/issue-briefs/2017/oct/payingprescripton-drugs-around-world-why-us-outlier.

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Nursing Division

Section Editor:

Catherine G Winkler, PhD, MPH, APRN-BC

Director of the Nuvance Health Global Health Program Nursing Division

How do we recruit and retain Nurses?

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Written by

Catherine G Winkler, PhD, MPH, APRN-BC

Director of the Nuvance Health Global Health

Program Nursing Division

As the world struggles to recover from a

pandemic, a shortage of nurses currently coupled

with an anticipated increase in patient care

needs requires the profession to work efficiently

to recruit and retain nurses.

Nursing shortages have occurred often over the years so we have some strategies

that can be employed but it will take a concerted effort to maintain approaches

that will allow the profession to flourish with both novice and expert nurses

employed in key areas of clinical care.

To begin with comments made by International Council of Nurses Chief Executive

Officer, Howard Catton holds true in that, ‘The value of nurses has never been

clearer not only to our healthcare systems but also tour global peace and security.

Nor could it be any clearer that not enough is being done to protect nurses and

other healthcare providers……We should not shy away from calling out that this is

a question of policy and politics….. Access to healthcare is central to safe, secure,

economically successful, and equitable societies, but it cannot be achieved unless

there are enough nurses to provide the care needed…. Governments should be

urgently prioritizing investment in nursing and the healthcare workforce…..

Contacting government officials and using professional organizations to advance

policy change is a place to start. As an example, there is a toolkit available

through the World Health Organization (WHO), Strategic Directions for Nursing

and Midwifery: 2021-2025 (SDNM) which supports policy focus areas of education,

jobs, leadership, and service delivery as well as the actions needed to institute

a new practice. The toolkit has examples to support recruitment and retention

-i.e., Enabling actions: “Bundle” retention policies that cover education, regulation,

incentives, and personal and professional support. Consider a “rural pipeline” of

students who undergo health professional training and return to their communities

to practice. Implement legislative and administrative social protections, including

practice indemnity for infection, disability, or death, paid sick leave, and

occupational risk insurance. …….. and it continues (WHO, retrieved 8-22). These are

tangible actions that can be taken to secure a nurse’s position.

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Further at the legislative and organizational levels, ensuring the safety and wellbeing

of the nurse as well as colleagues is important now more than ever and in

preparation for the next pandemic wherein nurses are protected and supported

with policy and procedures, education and equipment and staffing to keep them

safe. According to WHO healthcare workers represent less than 3% of the global

population but represented 14% of the COVID-19 cases and in some countries

the proportion was as high as 35%. Not only should policy and procedures be put

in place at healthcare organizations now, but the awareness of these practices

needs to circulate to all nurses as well as their colleagues.

Retention can be improved with better orientation programs with built in support

or as Dr. Woods, a nurse practitioner from Penn Medicine and chief nurse at

Wolters Kluwer Health (Beckers, 2022) recommends extern programs set up by

academic centers with healthcare institutions. Externs who then stay with the

organization. This strategy supports the novice nurse and helps the organization

with recruitment as well to go on to having experienced nurses who stay to

continue to learn as well as educate new staff members. Through thoughtful and

secured recruitment and retention, efficiencies and cost savings are gained as

well as continuity of care which are best for patient care too.

Ongoing considerations would target well-being through implementation of

programs that integrate work-life balance with flexible staffing models, selfscheduling

and professional autonomy. Additionally, availability of continuing

professional development education programs that are valued, accessible and

relevant are important to promote within organizations and when available

partnered academic centers. Additionally, application of knowledge and skills is

also vital to work satisfaction and retention of nurses.

Another strategy that would likely promote education and application of

knowledge would be the opportunity for nurses to cross-educate into other

practice areas and environments. This would expand nurses’ knowledge and

skills, help them to better understand another practice area, develop a better

understanding and coordination of patient care across health care and facilitate

collegial relationships. It also has the potential to improve staffing.

Nursing leaders need to address the areas of education, policy, workplace safety

and support of nurses working to their full potential. However, key to success

in recruitment and retention is knowing your nurses and asking them – often –

what is best for you and what is best for our patients. Remember, they know,

and the best outcomes will be obtained by asking them and then acting on their

recommendations.

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Women’s Health Education

Cervical Cancer

Written by Sarah Cordisco, BSN, RN

Staff Nurse at the University of Vermont

Cervical cancer is the fourth most common

cancer women experience globally. The World

Health Organization estimated that in 2020,

there were 604,000 new cases of cervical

cancer and 342,000 deaths, with about 90%

of these new cases and deaths occurring in

low- and middle-income countries. About

95% of cervical cancer is caused by the human

papillomavirus (HPV) (Cervical Cancer, 2022).

HPV is one of the most common sexually

transmitted infection, with most sexually

active people becoming infected at one point in their lives. Generally, more than

90% of infected people will clear the infection.

HPV has more than 200 different viral variations, all which are spread through

sexual contact. While most of these HPV types are low risk (meaning they cause no

severe infections), there are 14 high-risk HPV types that can cause different types

of cancer. Most types of HPV contracted are low risk and will clear on their own,

there is always a risk that an HPV infection will become chronic and pre-cancerous

lesions will progress into cervical cancer (HPV and Cancer - NCI, 2019). For people

with a normal, healthy immune system, it may take 15-20 years for cervical cancer

to develop (Cervical Cancer, 2022). For those with weakened immune systems, like

those with an HIV infection, it can take only 5 to 10 years to develop. Women with

HIV are 6 times more likely to develop cervical cancer than those without HIV, and

about 5% of cervical cancer cases can be attributed to HIV. Cervical cancer caused

by HIV disproportionately affects younger women.

The HPV vaccine, Gardasil 9, protects against infection of 9 types of HPV: two lowrisk

types that cause most genital warts, and the seven high risk types that cause

most cancers. The vaccine can protect against new HPV infections and cancers,

though it does not cure an infection once you have it. Typically, this vaccine is given

to kids aged 9-12, and protects up to 90% of HPV-related cancers (HPV and Cancer

- NCI, 2019). Children who receive this vaccine before age 15, only need two doses

for protection, whereas those older will need three doses. Typically, this vaccine

offers the best protection when given to younger children, but it may be given to

adults. Adults benefit less from this vaccine, as they are more likely to have already

been exposed to HPV. Screening for HPV is done in order to find precancerous cells

at an early stage and to treat them before they become cancerous. Screening

tests include the HPV test that checks for high-risk HPV, the pap smear which

checks for cervical cell changes and the HPV/Pap cotest, which checks for both.

Screen should start at age 30 for the general population with regular screening

every 5-10 years after. For those living with HIV, screening should start at 25, and

be completed every 3 to 5 years (HPV and Cancer - NCI, 2019).

In high-income countries, many programs are in place where women and young

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girls are able to be vaccinated and regularly screened. Regular STI screening

is extremely important, especially in the case of HPV, as precancerous lesions

are more likely to be identified early enough where they can be treated. In

low- and middle-income countries, there is often limited access to these types

of preventative measures, and cervical cancer may not be identified until it

has progressed and causes symptoms to develop. Women with less access to

preventative measures, also have less access to treatment of cancerous lesions.

This results in a high death rate in these types of countries (Cervical Cancer, 2022).

Treatment for cervical pre-cancer includes ablative treatment with cryotherapy

or thermal ablation. Both are effective and performed in an outpatient clinic.

In cases where the person is not eligible for ablative treatment, or if there is

suspicion of cervical cancer, women need to be referred to other health services

for proper evaluation that can be done with a colposcopy and biopsies (Cervical

Cancer, 2022). Excision treatment is also offered when appropriate, and in the

case of cancer, an individual treatment plan is created depending on the stage

of disease, patients medical condition and preferences, and the availability of

healthcare resources (Cervical Cancer, 2022).

Most women do not experience symptoms until the infection has become

cancerous. Symptoms of early-stage cervical cancer include irregular bleeding

or spotting, postmenopausal bleeding, bleeding after sex and increased vaginal

discharge which may have a foul odor (Cervical Cancer, 2022). As the cancer

advances, more severe symptoms may develop such as, persistent back, leg or

pelvic pain, weight loss, fatigue, foul smelling discharge and vaginal discomfort

and swelling of one or both legs. Diagnosis of cervical cancer must be made

by histopathologic examination and staging is then done based on tumor size

and the spread of the disease. Treatment options depend on the stage and may

include surgery, radiotherapy, or chemotherapy (Cervical Cancer, 2022).

The World Health Organization has worked on creating a global strategy for

eliminating cervical cancer as a public health problem. The elimination of cervical

cancer is defined by the WHO as less than 4 cases per 100,000 women a year.

WHO has set up the 90-70-90 targets to be reached by 2030. The 90-70-90

targets mean that 90% of girls are fully vaccinated with the HPV vaccine by age

15, 70% of women are screening with a high-performance test by 35 and again

by 45, and 90% of women identified with cervical disease receive treatment (90%

of women with pre-cancer treated and 90% with invasive cancer managed)

(Cervical Cancer, 2022).

References

Cervical cancer. (2022, February 22).

https://www.who.int/news-room/fact-sheets/detail/cervical-cancer

HPV and Cancer—NCI (nciglobal,ncienterprise). (2019, March 1). [CgvArticle].

National Cancer Institute.

https://www.cancer.gov/about-cancer/causes-prevention/risk/infectiousagents/hpv-and-cancer

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An American Nursing Student

Working in a Hospital in

Greece: An Experience of a

Lifetime

Part 2/2

Written by Amanda Towey

Nursing Student at Western Connecticut

State University

Amanda Towey participated in a student

exchange program between Western

Connecticut State University in Danbury,

CT, and International Hellenic University

(Alexander Campus) in Thessaloniki,

Greece. Program funding was provided

by Eramus, Dr. Monica Sousa, Professor

of Nursing from Western Connecticut

State University was the co-faculty lead

on this project.

The documentation and medication system is vastly different at Papageorgiou

Hospital. There is one computer on the unit for the charge nurse to use for labs,

printing labels and patient information, otherwise all documentation is done

on paper. Each patient has a binder with their information, medication, and

notes. This is where all interventions and procedures are documented, however

documentation is not as extensive as it is in the United States. At each patient

bed, there are papers to write down vital signs, intake and output, and to chart

blood products. Only when the patient leaves the unit do these papers get put

back into the binder and sent with him or her. Most of the medication used on A’XEI

is stored in the nurse’s station and in the fridge, there is no medication dispensing

machine. The nurses mix the medication and administer to each patient during

medication rounds which is done once in the morning at 0900 and again at 1300

for the day shift. There are no IV pumps used on the unit, they use IV lines with

dials that control the drip rate. The only pump used is for feeding tubes which are

identical to the ones in the United States.

The role of the nurse is quite different in Greece, however, to become a nurse is

similar. There are two options: a four-year degree in nursing, or a two-year degree.

The difference between the two routes of education is shown in the workplace, the

nurses who have completed the two-year program cannot do charge nurse duties

or oversee the medication rounds. After the years of education, each student

nurse must complete six months of practice. These students spend a month on

six different units, Monday-Friday from 0730 to 1430. Their role changes from unit

to unit and depending on what the nurses need help for during that day. On the

unit, there is a nurse manager, who has a role like that of the nurse manager in the

United States. She has an office, fills out paperwork, does all the scheduling for

the nurses, and works closely with the doctors when they round on the patients.

The charge nurse works at the front desk, answers the phone, does all the lab

work for the patients on the unit at the start of the shift, and delegates duties

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to the nurses. The medicine nurse is in charge of going through all the patient

charts and preparing the medication and signing off on each patient chart

when a medication is given during rounds. He or she hands the medication to the

nurses helping in a container to be delivered and administered to the patient. The

remaining nurses share the duties amongst each other and make sure everything

is done as needed. Lastly, the student nurses on A’XEI, which I am considered

as well, take vitals, bathe patients, help administer medication, send labs, and

act very similarly to a patient care technician/CNA in the United States. As for

scheduling, there are three eight-hour shifts that the nurses work, a day shift,

evening, and night. The nurses work all three shifts and rotate each week. There is

no shift differential, and they do not choose what shift they get to work.

One nurse rounds with the doctor to assist with dressing changes, wound care,

drain care, ostomy care, foley insertions, etc. The nurse does not perform these

duties, he or she only assists the doctor. Nurses are allowed to insert foleys on

women, but not male patients, unlike the United States.

Although vastly different, working at Papageorgiou Hospital, specifically A’XEI has

been an experience of a lifetime and I have learned so much about healthcare in

Greece. The nurses have embraced me and taught me about their culture, and I

could not be more grateful.

Nursing Division

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Bubbles (Majid Sadigh)

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Among the Letters

“I am extremely grateful for my hosts during my time there, and I can’t wait to

(hopefully) return as a fourth-year medical student. I am glad I took myself out

of my comfort zone, pushed myself to learn many different things, and worked

through the difficulties the trip presented. This easily was one of the most formative

experiences of my life, and I look forward to being able to share my story with peers

and friends going forward.”

Highlights

John (Jackson) Burke

Medical Student Larner College of Medicine Class of 2025

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Among the Letters


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I was invited to join the palliative outreach program for a visit. The services that

they provide to care for these patients are amazing. They ensure to touch their

patients on all levels: economically, socially, spiritually, and medically to provide

comfort. All free of charge. It is fascinating to know that in a country like Uganda,

with their limited medical resources, they do care for those patients who need some

comfort due to the burden of terminal illness. Ironically, in the United States, we do

not have palliative care services except for a few academic facilities that strive to

make it an affordable and available service for their patients.

Dr. Bemen Habashi

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(Rose Schwartz)

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Editor; Dilyara F. Nurkhametova, MD, PhD

Let Us Together Explore Our Beautiful Planet

This new column exhibits the beauties of our planet earth and our everyday

destructive actions against it.

We are witnessing how our beautiful planet is undergoing profound transformation.

In this recently established section we would like to appreciate all the beauty

of our planet and raise awareness of warning changes. We are inviting all our

readers and GH community to contribute to this section. We are looking forward

to your photos, videos, inspirational resources, and stories from different parts

of the world. We want to hear from you how climate change affects people and

health in your part of the world. If there is anything you would like to share with us,

please don’t hesitate to contact me via my email:

dilyara.nurkhametova@nuvancehealth.org

We are looking forward to hearing from you!

Among the Letters


Art to Remember

Who We Can Be

“2022 heatwaves: a failure to proactively manage the risks”

The Lancet, Editorial;Vol 400 August 6, 2022

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In this Lancet editorial authors discuss this year’s heat waves across the world.

These extreme weather events require preparedness, adequate planning and

accessible resources. Available research should be translated into lifesaving

practice. To protect human lives we must understand current deficiencies and the

need for global political action.

Read the Article

2022 heatwaves: a failure to proactively manage the risks

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Education in Planetary Health

An open letter from WHO Civil Society Working group “A call for strengthening

climate change education for all health professionals”

“We, the WHO-Civil Society Working Group to Advance Action on Climate Change

and Health, urge the deans, academics, managers and other teaching staff of

health professional educational institutes, as well as the associated accrediting,

examination, and licensing bodies to ensure graduating health professionals are

prepared to identify, prevent, and respond to the health impacts of climate change

and environmental degradation.”

Read the full open letter from the WHO Civil Society Working group and explore

example courses on climate and health here

https://climateandhealthalliance.org/wp-content/uploads/2022/06/Curriculumletter.pdf

TelessaúdeRS-UFRGS is offering three Planetary Health courses, recommended

by WHO, for Portuguese and English speakers. The topics covered during these

courses include air and water pollution, food and food systems, mental health,

heat waves, and infectious diseases.

You can enroll in these courses using this link

https://moodle.telessauders.ufrgs.br/login/index.php

More information about the course

https://www.ufrgs.br/telessauders/documentos/cursos/course_manual_wonca_.pdf

Upcoming events

This year the Planetary Health Alliance (PHA) is hosting the 2022 Planetary Health

Annual Meeting.

The Promise of Planetary Health –

video

https://youtu.be/9cZ0zBSJz_g

The theme of 2022 Planetary

Health Annual Meeting is Building

the Field and Growing the

Movement. This year’s Annual

Meeting will be a free, fully-hybrid,

and interactive conference from

October 31-November 2, 2022.

Visit the conference website to

learn more about the conference’s

speakers, schedule, and more.

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Rethinking “Four Seasons”

Since Vivaldi composed his “Four Seasons”, the world and climate has changed

significantly. The NDR Elbphilharmonie Orchestra, musicologists and creative

coders established the project “For Seasons” https://www.forseasonsbydata.

com/theproject to make these changes audible.

Watch the video about the project

https://www.youtube.com/watch?v=VzFyrmzkmQw&t=1s

Vivaldi’s “Four Seasons” became “For Seasons” composed by climate data: Alan

Gilbert and musicians from the NDR Elbphilharmonie Orchestra performance.

https://youtu.be/3Z18FNApDg0

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Meeting the host of the ocean

Watch the video

https://drive.google.com/file/d/1-MoEKvsBYSyBUh_QnSd8cBUwQy9wldl9/

view?usp=sharing

Waterbear.com

If you are passionate about the future of our planet and appreciate quality

documentaries you may like to visit Waterbear.com website. Waterbear is the

first interactive streaming platform dedicated to the developments of our planet.

On this platform you can find documentaries, NGO campaigns, and locally-told

stories. Using storytelling as a tool for making a difference it provides access

to award-winning and inspirational content that empowers members to dive

deeper, learn more and take action.

One of the documentaries available on waterbear - Racing Extinction, directed

by Louie Psihoyos, exposes the hidden world of endangered species and the race

to protect them against mass extinction.

https://www.waterbear.com/watch/feature/62ba43c6133ee90cb13fd53c?utm_

source=SAPHybris&utm_medium=email&utm_campaign=317&utm_term=Week%20

32%20content%20drop%20-%202022___Watch%20Now&utm_content=EN

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Art To Remind Us

of Who We Can Be

Editor: Majid Sadigh

Contributing Editor: Mitra Sadigh

During times of confusion, tribulation, grief,

uncertainty, and despair, the arts enliven

us by reintegrating the disjointed pieces of

ourselves and replenishing them with clarity

and hope. The arts remind us of our individual

and collective potential to grow, evolve, and

transform. They remind us of what and who we

can be and what we can create. In this new

section, we bring you works of art that have

moved and inspired us. We encourage you to

also share works that have inspired you.

Nursing Division

Among the Letters


Art to Remember

Who We Can Be

Article of he Month

Art in the Time of

Pandemic

By Anne-Ryan Sirju

Columbia College Today

Spring/Summer 2022

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Saint Charles Borromeo

among the Plague-Stricken

of Milan; Pierre Mignard,

1646-50

We can relate to depictions

of suffering, but also to

images of hope. This old art

still can speak to today.

As the world has gone into quarantine to combat the spread of COVID-19, many

scholars are looking to the past to see how populations have handled pandemics and

isolation. Art has long been a way for societies to cope with tragedy and uncertainty,

so Columbia College Today recently sat down (remotely!) to talk about art, plagues

and resilience with classmates Franco Mormando ’77, professor of Italian and chair of

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the Department of Romance Languages and Literatures at Boston College, and

Thomas Worcester ’77, professor of church history and president of Regis College

in Toronto. In 2005, Mormando and Worcester co-curated an exhibition, Hope

and Healing: Painting in Italy in a Time of Plague, 1500–1800, at the Worcester

Art Museum in Worcester, Mass. The show examined visual art as a response to

repeated outbreaks of bubonic plague in Europe. The pair collaborated again in

2007 as co-editors of the book Piety and Plague: From Byzantium to the Baroque,

which examines the religious, cultural and psychological aspects of pandemic.

Following are edited excerpts of the discussion.

Read the Article

Art in the Time of Pandemic By Anne-Ryan Sirju

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(Elina Mukhametshina)

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Article of the Month

“Every challenge is here”: fistula in Ethiopia

Ethiopia was making good progress to eliminate obstetric fistula, until the war

came. Sophie Cousins reports


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In 1958, obstetrician and gynecologist Catherine Hamlin and her husband—also a

doctor—answered an advertisement in The Lancet to set up a midwifery school in

Addis Ababa, Ethiopia. Within days of arriving, the Australian couple saw obstetric

fistula cases for the first time. Obstetric fistula is a hole between the vagina and

rectum or bladder that is caused by prolonged obstructed labor that leaves a

woman incontinent of urine or feces. It can be prevented with access to timely and

skilled maternal and newborn care. The condition was overwhelmingly common

in Ethiopia because of a lack of access to health facilities and skilled health

professionals, particularly in rural and remote areas.

Read the Article

“Every Challenge is Here” Fistula in Ethiopia

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Poliomyelitis - poliovirus


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Polio in New York

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Watch “Why Monkeypox Is a Global Health Threat | WSJ” on YouTube

“Why Monkeypox Is a Global Health Threat | WSJ”

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Dr. Saida Agliullina and her family in Bukhara

Aida Trondina

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Dr. Bulat Ziganshin and his family, Winter Green Lake, Hamden

Daniile Ziganshin and

Eseniya Ziganshina

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The innocence of childhood-

Henry Scholand, aged 4 (Stephen

Scholand)

Dr Steve Scholand and daughter Krishna Scholand touring Bowdoin

College in Maine (Stephen Scholand)

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Calendar of Events

Nuvance Health

August 6: In-person meeting with Dr. Bulat Ziganshin, associate director of the

Global Health Program at UVM COM/Nuvance Health, to discuss the vision and

mission of the Global Health Academy and Global Health Bridge

August 7: Zoom meeting with Dr. Scholand, course director of the Global Health

Bridge, to review finalize the content and structure of the first Global Health Bridge

at Nuvance Health

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August 8: In-person meeting with Wendi Cuscina, manager of the Global Health

Program, to discuss the fiscal budget and new responsibilities for current global

health program staff

August 8: UN Training Session

August 9: Zoom meeting with Dr. Steve Winter to discuss designing CME program

for Vietnamese colleagues at Cho Ray Hospital

August 10: Discussion with Dr. Robyn Scatena in designing CME program for

Vietnamese colleagues at Cho Ray Hospital and inviting Nair Global Health

Scholars from Cho Ray Hospital to Norwalk Hospital for observership

August 10: Zoom meeting with Dr. Swapnil Parve in preparation of his trip to India

August 12: Reviewing Global Health Bridge with a medical student

August 13: Inviting Dr. Alex Kayongo to Global Health Bridge at Danbury Hospital

August 13: Reviewing the Global Health Bridge with Dr. Stephen Scholand

August 13: Reviewing questions for one of the global health sessions with Dr. Elina

August 14: Zoom meeting with Dr. Steve Scholand to discuss his upcoming trip to

Thailand and the Philippines

August 14: Zoom meeting with a global health faculty member

August 17: Zoom meeting with a member of the UNGA panel on decolonization of

global health

August 18: Weekly touch-base with Wendi Cuscina

August 18: Reviewing Global Health Bridge with Joanna Coklin

August 18: Meeting with Amanda Wallace regarding the format of the Global

Health Bridge program

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August 22: Touch-base meeting with Dr. Swapnil Parve

August 22: Touch-base meeting with Wendi Cuscina

August 22: Interviews with cardiology residents from the Heart Institute in the

Dominican Republic

August 22: Touch-base with Dr. Dilyara Nurkhametova

August 23: Weekly touch-base meeting with the global health team

August 24: Interview meeting with Global Health Scholar candidates from ChoRay

Hospital in Vietnam

August 24: Meeting with Dr. Dilyara Nurkhametova and a surgical resident at

Danbury Hospital interested in global surgery and research

August 24: Touch-base meeting with Dr. Swapnil Parve to discuss his current

immigration status

August 25: Discussion of the availability of global health electives and resources

in American residency programs in surgery with one a senior RUSM student

August 27: A follow-up meeting with a medical student from Stony Brook to

discuss an ongoing research project

August 27: A follow-up meeting with a medical student from RUSM to discuss an

ongoing research project

August 29: Weekly touch-base with Wendi Cuscina

August 29: Meeting with a senior RUSM student interested in global health before

his travel to Nagallama

August 29: Touch-base with Dr. Scholand in preparation for Global Health Bridge

August 29: Touch-base with speakers of Global Health Bridge

August 30: Meeting with Dr. Dilyara Nurkhametova and the leadership of University

of Medicine and Pharmacy to discuss logistics of starting the partnership

August 30: Weekly touch-base with the global health team

AUC/RUSM

August 2: Touch-base meeting with Dr. Elina Mukhametshina

August 9: Orientation meeting with Ali Sadeghi (AUC) in preparation for the Global

healthH elective in Uganda during Sep 26 - Nov 4, 2022

August 15: Ashley Diaz (AUC), Danielle Azani (RUSM), Nistha Acharya (RUSM)

started their GH elective at Datta Meghe Institute of Medical Sciences, India

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August 22: Interviews with three candidates for GH electives in 2023

August 23: Interviews with seven candidates for GH electives in 2023

August 23: Reflections project discussion with Svanjita Berry (RUSM) and Amanda

Hererra (RUSM)

August 29: Interviews with ten candidates for GH electives in 2023

August 30: Reflections project progress update with Svanjita Berry (RUSM), Salwa

SadiqAli (RUSM) and Amanda Hererra (RUSM)

Highlights

Spotlight

Reflections


Borders

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UVMLCOM

August 8: Global Health Leadership Team meeting

August 9: Dr Mariah McNamara and Dr Amalia Kane conducted GH elective

debrief session with UVM medical students Joanna Pierce and Justin Heningsen

August 22: Global Health Leadership Team meeting

August 30: Dr Amalia Kane conducted GH elective debrief session with UVM

medical students Jackson Burke and William Hsu

Among the Letters


Art to Remember

Who We Can Be

Article of he Month

Videos of the Month

GLOBAL HEALTH BRIDGE

September 1st , 2nd, 2022 and February 3, 2023


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Latinx Panel lead by Jett Choquette

Click here to visit the Global Health Bridge website for details.

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Global Health

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Highlights

Spotlight

Reflections


Borders

Nursing Division

Among the Letters


Datta Meghe Institute of Medical Science (DMIMS)

Art to Remember

Who We Can Be

Article of he Month

Videos of the Month


Calendar

Photo News

Resources

Medical Students in India

Danielle Azani, RUSM, Nistha Acharya, RUSM,

Priyanka Nimje, Administrative officer, DMIMS,

Liana Galimova, KSMU

36

OUR PEOPLE,

OUR MISSION

Global Health

eMagazine


Highlights

Nistha Acharya (RUSM), during sightseeing in India

Spotlight

Reflections


Borders

Nursing Division

Among the Letters


Dr. Andrea Green with Dr. Mupere, Head of Paediatrics

Department at MakCHS, Uganda

Art to Remember

Who We Can Be

Article of he Month

Videos of the Month

Dr. Bremen Habashi in a lab at ACCESS


Calendar

Photo News

Resources

Dr. Mariah McNamara (second from left) and

Dr. Andrea Green (first from right) with the leadership

of ACCESS in Nakaseke, Uganda

Drs. Bemen Habashi and

Dr. Hamidah Babirye

37

37

OUR PEOPLE,

OUR MISSION

Resources

Global Health

eMagazine


Highlights

Spotlight

Reflections


Borders

Nursing Division

Among the Letters


Art to Remember

Who We Can Be

Article of he Month

Videos of the Month


Calendar

Photo News

Resources

Yale Medicine 2008

Photos and Reflections 2021

Global Health & the Arts

Nuvance Health and UVMLCOM Global

Health Website


Nuvance Health and UVMLCOM Annual

Report 2020

AUC/RUSM Annual Report 2018

Cases and Reflections from Mulago

Climb for a Cause 2018

Climb for a Cause 2019

Ebola: Sequences on Light and Dark

Ebola: Two Doctors Respond to the 2014

Ebola Epidemic in Liberia: A Personal

Account

Global Health Annual Reports

Global Health Conference 2019 Photos

Global Health Conference 2019 Videos

Global Health Conference 2019 Book

Global Health Diaries and Newsletters

2015-2016


2016-2017


2017-2018

Global Health Diaries and eMagazines

2018-2019

Global Health eMagazines 2020-2021

Global Health Diaries 2020-2021

Global Health Reflections and Photos 2017

and 2018

Global Health Reflections and Photos 2019

Ethical Dilemmas book

Global Health Program Website

Global Health at WCHN Facebook

Ho Chi Minh City and Cho Ray Hospital

The Homestay Model of Global Health

Program video

Kasensero Uganda

Nuvance/MakCHS Global Health

Information Center Booklet

Paraiso and the PAP Hospital

Photographs from Uganda, by

photojournalist Tyler Sizemore

Presentations By Global Health Scholars

Previous issues of the Global Health

eMagazine

Program Partners

Publications

Site Specific Information

Tropical Medicine Booklets (101, and

202)

Tropical Medicine Spanish 101

Tropical Medicine Courses

The World of Global Health book

The World of Global Health Video

Words of Encouragement

UVM Larner College of Medicine Blog

Participant Guide in Global Health,

Thailand

Cho Ray International Student Handbook

DRC Facing a New Normal

Photos and Reflections 2019

Coronavirus 2019 Important clinical

considerations for Patients & Health

care Providers

Interviews

A Connecticut Doctor in Africa, by

journalist Mackenzie Riggs

Majid Sadigh, MD Interview Regarding

Ebola in Liberia (Video)

My Heart Burns: Three Words Form a

Memoir (Video)

Two UVM Docs Combat Ebola in Liberia

(Article)

38

eMagazine September 2022

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