May 7, 2019

In Sri Lanka, a student helps create a diabetes management program

Anjan Saha leads two separate lives in medical school.

An MD-PhD student in the Medical Scientist Training Program, Saha spends much of his time in the lab on basic cancer research – sequencing tumor tissue, studying gene expression profiles inherent to certain cancers, and the like. In December 2018, he was part of a team that published a paper, The DEK Oncoprotein Functions in Ovarian Cancer Growth and Survival, in the journal Neoplasia.

UMMS MD-PhD student Anjan Saha at this year's CUGH conferenece  presenting on his work in Sri Lanka.

That same month, Saha authored a second publication, this one in Clinical Diabetes Endocrinology, titled, A New Model for Diabetes-focused Capacity Building: Lessons from Sri Lanka. If those two subjects – DEK gene expression and chronic disease management in the developing world – sound about as far apart as Ann Arbor and Sri Lanka, that’s because they are.

“Sometimes, I will talk to my colleagues in the lab about my work abroad. I think they are perplexed by it, and I get that. When I step back and think about it, I am perplexed by it, too, because I came into medical school thinking that my interest was in pure science,” Saha said. “But being involved in global health has expanded my interests.”

For the past four years, in addition to working on his PhD, Saha has been occupied by a project that seeks to improve care around diabetes management in Sri Lanka even as it creates a new career path for a largely overlooked segment of the population: women orphaned by the country’s decades-long civil war. The initiative, which involves training girls aging out of the orphanage system to be community health workers specializing in diabetes screening and management counseling, is being conducted under the direction of Ann Arbor gastroenterologist Naresh Gunaratnam. A native of Sri Lanka, Gunaratnam founded an orphanage for girls in Trincomalee, on Sri Lanka’s northeastern coast, in 2002 and has since led more than 50 U-M medical, business, and undergraduate students on volunteer service trips to the facility, called the Grace Girls’ Home.

“Over the course of 17 years, our girls grow. They need a job. At the same time, there’s a great need for diabetes care in the country,” said Gunaratnam, MD. “The thinking was, can we leverage something to address both of these needs?”

Saha was part of a student team that traveled to Sri Lanka with Gunaratnam in December 2015 to conduct a proof-of-concept pilot project that trained a handful of women at the orphanage to help staff a temporary diabetes-focused clinic in an unused space at the Grace Girls’ Home. Saha helped teach them how to perform basic tasks including taking a patient’s blood pressure and measuring blood sugar levels, managing intake and patient flow, maintaining records, and so forth.

Subsequently, additional training included refining skills to help counsel patients about diabetes – preventing high risk patients from progressing and managing diagnosed disease through lifestyle interventions – conversations that overburdened physicians in Sri Lanka rarely have time to have with patients. Their pilot study, the subject of the December 2018 article in Clinical Diabetes Endocrinology, demonstrated the feasibility of the model and paved the way for expansion. The initial cohort of trained medical assistants is now actively managing more than 500 diabetic or pre-diabetic patients in and around Trincomalee, with plans to expand to other areas of the country through coordinated partnerships with the Ministry of Health affiliates. They also plan to incorporate hemoglobin A1C testing, the gold standard for screening, diagnosis, and disease monitoring, to better show clinical outcomes from the program.

Former residents of the Grace Girls' Home orphanage are now being trained as medical assistants to address Sri Lanka's emerging problem with diabetes.

Saha has been a catalyst for the work. He most recently visited Sri Lanka (with financial support from Global REACH) and has been helping to oversee fellow students traveling there for the project as well. He was first author on the publication in Clinical Diabetes Endocrinology and presented a poster on the project at the spring’s Consortium of Universities in Global Health meeting in Chicago.

“Anjan has been a leader and champion for the project. Without his passion and expertise, we would not have been able to accomplish what we have,” Gunaratnam said. “He has tirelessly worked with other medical students and Ross Business School students who developed the business plan for the program.”

Saha is set to defend his PhD thesis this summer before re-entering medical school in the fall as an M3. His upcoming busy clinical training schedule likely won’t leave time for another in-person visit in the near future, but he remains heavily involved. He recently wrote a grant with Michigan Medicine Professor of Internal Medicine William Herman for resources to bring in new collaborators, including Dr. Prasad Katulanda, who is a luminary endocrinologist in Sri Lanka, and Charles Conconi, a USAID project lead with ties to the Sri Lankan Ministry of Skills Development and Vocational Training, who can help with program accreditation and scaling. He is also actively working with Drs. Ulysses Balis and Jennifer Wyckoff to improve the technologic and informatics capacity of the initiative while further enhancing the training the girls receive.

“My clinical rotations schedule will kind of force me to take a backseat, but I will still play an advisory role,” Saha said. “What I find most exciting is the idea that this work actually has the potential to become fully self-sustainable, both medically and financially. It’s true capacity building. I want to see it through.”

Recent violence in the country, which included incidents in Trincomalee, have not disrupted those plans. (If anything, the events highlighted the need for increased resources to improve stability for the residents of Grace, many of whom already have a history of PTSD because of their own past, as Gunaratnam noted during a recent interview with Michigan Radio’s Stateside.) Global Health projects like his in Sri Lanka can be a good opportunity for students to make a meaningful difference, Gunaratnam said.

“In developing countries, small changes can have huge impacts. You’re essentially bringing water to the desert,” Gunaratnam said. “For instance, in Trincomalee, we now have approval for a prospective study looking to see if our model utilizing trained medical assistants is better than the usual care, from an outcomes perspective. If it is proven more effective, then thousands of patients will benefit.”