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Community-Based Managment of MultidrugResistant Tuberculosis in Rural Kwazulu-Natal

uberculosis (B), caused by the Mycobacteriumtuberculosis bacilli, is a disease that dates back as ar as500,000 years [1]. B is particularly problematic among

poor and marginalized populations in resource-poor areas, and itremains endemic in many low-income countries in Arica, Asia,Europe, and South America. It is estimated that one third o theworlds population (2 billion people) is inected with the bacillus,although the majority o these cases are latent or asymptomatic[2-4]. B usually attacks the lungs but can affect other areaso the body as well, such as the spine, kidney, or brain. Whenpeople have an active inection cough, they propel B bacilli intothe air, spreading inection. South Arica has the third highestprevalence rate o B in the world, lagging behind only Chinaand India [5]. uberculosis is a major source o morbidity andmortality in South Arica, causing 5.5% o total deaths and posing

a significant hindrance to the development o the country [6].Over the past several decades, a new threat has emerged

Multi-Drug Resistant uberculosis (MDR-B), defined as anystrain o B resistant to the most efficacious first line drugisoniazid (INH) and riampin (RIF) [7]. Cases o MDR-B areinordinately concentrated in resource-poor areas o AricaEastern Europe, Asia, and South America. Unortunatelymedical acilities in South Arica are not sufficient to treat thgrowing number o MDR-B cases. In 2010, the amount o newMDR-B cases in the province o KwaZulu-Natal exceeded thenumber o available beds in MDR wards by 352 [5].

While studying abroad or our months in South Arica, had the opportunity to conduct a research project ocused on threcent epidemic o drug resistant B in KwaZulu-Natal, SouthArica, a province that has the highest burden o drug resistanB in the country. reating MDR-B is an 18-24 month processand the majority o this process occurs outside o the hospital. explored the various services that have been established to managMDR-B in the community and the workers who provided thesservices and analyzed the findings in a rural context to determinthe difficulties associated with providing care. Drug resistant Bis a growing epidemic that shows no signs o receding. o addres

this epidemic and reduce MDR-B globally, it is imperative thahealth systems invest in the support structures responsible omanaging MDR-B at the community level.

Methodology

Tis project was conducted over a 3-week period in thcatchment [1] area o a rural hospital in northern KwaZuluNatal, where a variety o community-based activities thacontribute to the surveillance, control, and treatment o MDR-Bwere observed. Primarily, qualitative data was gathered throughnumerous inormal conversations with health proessionalsTis was supplemented with a variety o secondary sources romacademic journals and websites. Te hospital and all hospitapersonnel will remain anonymous throughout this paper toprotect their integrity and privacy. Te hospital will be reerredto as Hospital X. Hospital X is a 280-bed district hospitalbelonging to the KwaZulu-Natal Department o Health. It servea predominantly Zulu population, with some patients crossingthe border rom Mozambique to receive care.

Results and Discussion

Home Injections

An effective treatment regimen or a patient that presentwith MDR-B typically lasts between 18 and 24 months, and

Michael Celone

ulane University

Abstract

Multidrug Resistant Tuberculosis (MDR-TB) is a signicant

health burden in South Africa, and it is particularlyproblematic in the region of KwaZulu-Natal. MDR-TB isnot susceptible to most rst-line medications, and anti-

bacterial treatment for resistant bacteria may take up to

24 months to complete. The majority of this treatmentprocess occurs outside the connes of the MDR-TB ward

in the community. This project examines the provision of

community-based care to MDR-TB patients in a rural areaof Northern KwaZulu-Natal, and attempts to understand the

multifaceted system of MDR-TB control.Community-based care is one of the essential steps in

the treatment of MDR-TB due to the lengthy treatmentprocess and the potential for adverse side effects. Withouta comprehensive system of community-based care, MDR-

TB has the opportunity to proliferate and to amplify itsresistance. This project explores the roles, motivations,

and skills of various community caregivers who areresponsible for treating and overseeing MDR-TB patients

in the community, such as the TB tracers, injection nurses,home assessors, and community health workers who all

play integral roles in managing MDR-TB. Participantobservation and informal conversations with these hospitalpersonnel allowed for a comprehensive understanding

of the management of MDR-TB in the community, and toassess the obstacles to care posed by a rural environment.

This experience led to the conclusion that a comprehensive,community-based strategy is necessary for the containmentof MDR-TB and that signicant funding should be allocated

for strengthening MDR-TB control systems.

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this necessitates the provision o injections directly to the home[8]. Tose who test positive or MDR-B are hospitalized in theMDR-B ward and immediately started on injection therapy witheither amikacin (AMK) or kanamycin (KM). Tis injection isadministered to the patient six days a week or approximately twomonths in the hospital ward. Each month, patients must providea sputum sample to test or the presence o bacilli. ypically thepatients sputum (mucus rom the lower airways) will convertto negative afer a period o two months on injections (Nurse

1, Personal Communication, November 8, 2011). According toDepartment o Health policy, patients who have negative sputummicroscopy and who are clinically not too ill may be initiated onMDR-B treatment as outpatients i access to daily injections canbe organised. [2]

MDR-B patients should be visited at home by a mobileteam five days a week or the duration o the injectable phaseo treatment. During visits, the team will administer injectabledrugs, monitor side effects, provide health education, andassess household inection control practices [2]. Tis constantmaintenance is essential, because the interruption o injectiontreatment may ampliy the already resistant bacilli, leading toextensively resistant bacteria.

Hospital X has implemented a community-based program toensure that all MDR-B patients adhere to the 6-month injectionregimen even afer discharge rom the hospital ward. One nurserom the HAS (HIV, AIDS, and Sexually ransmitted disease)ward has the sole responsibility o driving to the homes o MDR-B patients and administering injections. It is impractical toassume that the patients or their amily members are capable oproviding injections due to the difficulty o such a procedure. Itis also unrealistic to keep MDR-B patients in the ward or theduration o the 6-month injection treatment, as resident patientsmust be discharged to make room or new ones. Tereore,community-based injection treatment is an essential aspect o asuccessul MDR-B treatment program.

It is also important to consider the impact o injectiontreatment on children inected with MDR-B. Six months oinjections place a heavy burden on both the child who must endurethe painul procedure and the healthcare proessional who mustadminister the treatment. As one nurse stated, Another challengeis treating the children with injections. Children normally crywhen you give them immunizations, so imagine giving injectionsor six months? Its not easy to be their enemy (Nurse 1. PersonalCommunication. November 8, 2011). In some situations, theinjection nurse may be orced to administer treatment while thechild is at school, which may reinorce the stigma surrounding Band exacerbate the emotional strain or the child. Te injection

nurse at the hospital commented on this scenario: SometimesI must give injections at school and when the other childrensee them [the patients] getting the injections they will makeun o them [the patients] and isolate them because they thinkthey [the patients] are sick (Nurse 1. Personal Communication.November 8, 2011). Tereore, community support structuresmust be established or children who are subjected to treatmentor MDR. It is also essential that the patients peers are educatedabout the condition so misconceptions are not perpetuated andchildren are not ostracized as a result o their condition.

Linking Patients with a DOT Supporter

DOS (directly observed therapy short-course) has been thecornerstone o B treatment regimens since it was establishedin the 1980s by a doctor in anzania, and successul treatmentoutcomes are predicated rom the implementation o an effectiveDOS program [7]. DOS is a comprehensive program that relieson government support, a steady supply o antituberculosis drugsa successul monitoring system, and diagnostic capabilities. Tecentral tenet o DOS is that all doses are taken under the direct

supervision o another individual (a DO supporter), in order toensure patient compliance [4].

Directly observed treatment takes on a greater significancein the context o MDR-B due to the duration o treatment andthe complications associated with treating drug resistant strainsTe 24-month treatment regimen increases the probability ointerruption or deault in comparison to the six month, shortcourse regimen (Nurse 3, Personal Communication, November14, 2011). In addition, adverse reactions to treatment areincreasingly likely with second line drugs. Many countries haveadopted a DOS-Plus program to combat MDR-B, which ismore complex than the traditional DOS strategy.

Te nurses at Hospital X must ensure that every MDR-B patient is linked with a DO supporter as soon as they aredischarged rom the hospital. Te DO supporters will supervisethe ingestion o treatment in the community and monitor anyadverse effects that develop. DO supporters must watch thepatients take their medication and record that they have done soon a card that is turned in at the monthly clinic appointmentsAt Hospital X, there is no specific DO protocol but it is theresponsibility o hospital personnel to link patients with a DOsupporter in the community (Nurse 3, Personal CommunicationNovember 14, 2011). In the majority o situations, the DOsupporter is a amily member, but community health workersneighbors, or home-based caregivers may also serve this role

When the patient is first registered in the MDR-B ward atthe commencement o treatment, he is required to provide thename o someone who will serve as the DO supporter or theduration o his treatment in the community (Nurse 2, PersonaCommunication, November 14, 2011). For example, one patienwho was to be discharged rom the MDR-B ward lived with twosons, both o whom were teenagers. While conducting the homeassessment, the nurse was concerned that the older son wouldnot be a suitable DO supporter due to his age and demeanorHowever, the nurse located a nearby amily member who waswilling to supervise the patient during the treatment regimenTe nurse deemed this woman better suited to the responsibilityo a DO supporter in this situation, and he proceeded to educate

her about her role in the patients treatment regimen. Te nursediscussed the duration o the treatment and the importance opatient compliance. Due to the remote location o many homeand the lack o health acilities in rural settings, amily membersare usually the only option or DO support. As one tracerstated there is no other way around (B Assistant, PersonaCommunication, November 3, 2011). However, according toDepartment o Health policy, Family members should be usedonly as a last option [or DO] because they may be coerced byother amily members, making them less objective as communitycaregivers. [2]

It is essential that hospital personnel develop a system or

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linking MDR-B patients with DO supporters i the patientlives alone or does not have an adequate support system at home.In this situation, home-based caregivers may be the only optionor DO support. Occasionally, community health workersmay act as a DO supporter, but this is rare due to their heavypatient burden. It is difficult or us to provide DO, lamentedone community health worker. Te patient must be observedevery day and we have too many patients to see so it [the DOsupporter] is usually a amily member. (Community Health

Worker 1, Personal Communication, November 9, 2011)Tereore, it may be necessary to employ home-basedcaregivers in the provision o directly observed treatment in thecommunity. A community health center, located just outside theHospital X gates, is an NGO that trains home based caregivers inthe provision o DO. Tese caregivers differ rom communityhealth workers in that their services are completely voluntary.Te NGO employs 130 such community volunteers who reachinto 45 o the 48 tribal areas in the Hospital X catchment area(NGO Personnel, Personal Communication, November 15,2011). I MDR-B patients cannot locate a DO supporter tosupervise their treatment regimen, the NGO is able to providethis service or the duration o the treatment regimen (Nurse

1, Personal Communication, November 8, 2011). It is evidentthat the successul treatment and surveillance o MDR-B inthe community is heavily reliant on community caregivers; theimpact o these non-proessional health workers in maintainingpatient compliance cannot be understated.

Preventing Interruption and Default: TB Tracers

Te interruption and deault o treatment among MDR-Bpatients is usually caused by the lengthy and grueling treatmentregimen associated with the condition. Interruption is definedas a ailure to take treatment or two months or less, whiledeault is a ailure to take treatment or over two months (B

Assistant, Personal Communication, November 3, 2011). Teactors that lead to deault among B and MDR-B patients arepoorly understood but ofen include personal stresses, such asalcoholism, pessimism, previous negative experiences with Btreatment, health care service limitations, and the need to earnmoney [9].

One o the most apparent reasons or the interruption oMDR-B medication is the potential appearance o side effects(Nurse 3, Personal Communication, November 14, 2011). All Bdrugs have been reported to cause adverse reactions and one o themost common side effects is progressive hearing loss [10]. Othercommon side effects range rom mild (dizziness, headaches,atigue, nausea, diarrhea, anxiety, etc.) to severe (depression,

seizure, peripheral neuropathy, psychosis, suicidal ideation, etc)[10]. According to the audiologist at Hospital X, approximatelynine out o ten MDR-B patients experience some level o hearingloss (Hospital Audiologist, Personal Communication, November8, 2011). Another common reason or deault is that patients startto eel better beore the treatment is complete. According to theinjection nurse at Hospital X, many patients stop their treatmentprematurely when their symptoms are alleviated. When weask the reason [or deaulting] it was that the patient was eelingwell. Tey decided to stop treatment because they are no longercoughing, they are no longer sweating at night, they think theyare fine (Nurse 1, Personal Communication, November 8, 2011).

However, patients are not ully recovered at this point and mustollow through with their drug regimen to ensure a positivetreatment outcome. Another nurse echoed these sentimentsattributing this behavior to a lack o proper patient education.

I think the people dont understand why they haveto be treated or so long when immediately they convert.With B, one becomes very sick, very quickly, and thenimmediately they commence the treatment they eel much

better and then they stop, and 3 or 4 months down theline they are completely better but they have to continuewith the treatment. I theyre not properly health-educatedthey will deault with the treatment (Nurse 2, PersonalCommunication, November 14, 2011).

According to Department o Health policy, one key elemenor a successul MDR-B program is the establishment ounctional deaulter tracing teams that conduct home visitsidentiy contacts and trace deaulters. [2] Te tracing team atHospital X are nurses associated with the HAS unit. Followingdischarge rom the MDR-B ward, patients must travel to ahospital or clinic or a monthly review, which includes a sputum

test, determination o weight and vital signs, monitoring o sideeffects, and collection o treatment (which is provided in tabletorm) (Nurse 2, Personal Communication, November 14, 2011)When patients ail to appear or their monthly appointmentstracer teams are sent into the community to locate them andbring them to the hospital. In addition, i the monthly sputumtest shows that a patient has converted rom negative to positivethe tracers are immediately sent into the community to locate thepatient and inorm him to return to the hospital. Efficient andwell-organized tracing can prevent the transmission o bacillamong amily members o inected patients. In certain situationsi the tracer believes a patients condition is too severe or homebased care, he may determine that the patient requires urther

hospitalization and return him to the ward, despite the act thathe has been discharged by a physician (B Assistant, PersonaCommunication, November 3, 2011). Tis prevents urthertransmission between those in the patients household.

racers may also be utilized to locate patients who haveinterrupted their injection treatment. Although it is rare, patientwho are still on injections may interrupt their drug regimen or

various reasons. For example, some patients experience noticeablepain during injections. One man was not present or his injectionand the nurse attributed this to his reluctance to endure the pain(Nurse 1, Personal Communication, November 8, 2011). As aresult o the pain associated with the treatment, some patientswill flee their home when they see the hospital personnel arrivingto administer injections. In this case, tracers will be sent to findthem and encourage them to adhere to the treatment.

Home Assessments

Afer the conversion o sputum to negative, MDR-B patientwill be released rom the hospital ward to return to their homesIt is imperative that health workers acilitate the transition romhospital to home or MDR-B patients. I a high quality o homelie is not maintained, there could be deleterious results or thepatient and the patients amily. In order to make certain thaMDR-B patients are being released to a home environment

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that is conducive to their medical situation, B tracers, nurses,or community health workers will conduct a home assessment.Department o Health policy dictates that home assessmentsinclude the ollowing:

Ensuring adequate ventilation/open windows, isolatingpatient (own bedroom where possible), promoting coughhygiene, ensuring that patients use surgical mask duringwaking hours while at home or when meeting with others;

reraining rom close contact with children; maximisingtime in open-air environment (e.g., receiving visitorsoutside) [5].

Te first consideration is ofen the patients sleeping situation:the patient must be isolated during the night to prevent urthertransmission o bacilli to amily members. It is also essentialthat the patient sleeps alone and that the sleeping room is well-

ventilated (Figure 1 or an example o a poorly-ventilated house).Tis may prove difficult i the patient lives in an overcrowdedhome. According to the B tracer, there may be a amily o9 living in one room and when they are sleeping they are allbreathing the same oxygen increasing the probability that the

inection will spread. I the patient cannot be isolated during thenight, the health worker must find other sleeping arrangementswith a neighbor, amily member, etc. (B Assistant, PersonalCommunication, November 3, 2011). I alternative arrangementscannot be coordinated, the patients discharge rom the MDR-Bward will be delayed.

Te assessment also serves as an opportunity or the healthpersonnel to educate amily members about the complexity othe MDR-B treatment process. It is important that both amilymembers and patients thoroughly understand the importance oadhering to treatment and the potential consequences i treatmentis interrupted. As one nurse stated, One o the most difficultthings about MDR is properly educating the patient and making

him understand the severity o the condition (Nurse 1, PersonalCommunication,November 8, 2011). I patients and amilies areproperly educated, the probability o patient noncompliance isdecreased and amily members gain the knowledge they need toprotect themselves. When I observed the education o a amilyduring one home assessment, the tracer surveyed the amily abouttheir knowledge o MDR-B, including symptoms and modes otransmission. He also emphasized the importance o adheringto the treatment, and described the potential consequences opatient noncompliance. Another aspect o the home assessmentis determining the patients proximity to a nearby clinic, whichis essential in a rural environment like the Hospital X catchmentarea, where MDR-B patients may live significant distances romthe hospital. As a result o the isolated and distant location omany patients, the hospital injections nurse may be unable toreach all patients to administer injection treatments. Tereore,the home assessor must determine the closest clinic or hospitalwhere the patient can receive injections.

Finally, the home assessor must ensure that the patient hasa stable living situation, with some level o amilial support, anda orm o income. As one tracer stated, Te patient may havehis own room, but is there anyone looking afer him, is there anyDO supporter? (Nurse 1, Personal Communication, November8, 2011). I the patients living situation is not conducive to hiscontinued improvement and overall wellbeing, interventions

rom social workers may be necessary. For example, the sociaworker may take measures to ensure that adequate ood isavailable, as many patients in resource-poor areas may not haveany means to generate an income and to maintain a balanceddiet (Nurse 3, Personal Communication November 14, 2011). Ithe home assessor determines that patients cannot maintain anadequate standard o living they may choose to consult a sociaworker, who can travel to the home o the patient and conduct hisown assessment to determine the appropriate course o actionI necessary, the patient may receive government nutritionaassistance. Te ederal government has established gran

programs to provide ood to those who cannot afford a sufficientdiet. In addition, many MDR-B patients may qualiy or ederagrants to supplement their income and aid in their continuedrecovery (B Assistant, Personal Communication, November 32011).

Difculties of Providing Care in a Rural Area

A rural environment poses many significant obstacles tothe provision o quality healthcare to MDR-B patients. In theHospital X catchment area, homes are dispersed over a widegeographic area, and many people reside a significant distancerom any type o medical acility or clinic. Tis is problematic

during the months ollowing discharge rom the MDR-B wardwhen a health worker must travel to the home o the patient toadminister injection treatment. For a our month period, MDRB patients must receive injectable second line drugs whilethey are living in the community, but i patients do not live inclose proximity to the hospital, it may be necessary to travel to anearby clinic to receive injections. Te hospital has establishedrelationships with local clinics in order to link MDR-B patientswith these healthcare acilities. However, in certain situationseven clinics are not able to provide MDR-B patients with thecare that they require. It is evident that some patients simplyreside too ar rom an established medical acility or a qualified

Fig. 1. An example of a rural road in the Hospital Xcatchment area. (Photo taken by author)

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medical proessional who is capable o administering injections.As a result, they are not able to receive their required our-monthregimen o injections (Nurse 1, Personal Communication,November 8, 2011).

In some instances, MDR-B personnel may find themselvesin the rare situation where it is simply ineasible to provideinjections in the community. In this case, it may be necessaryor the patient to remain in the MDR-B ward or six monthsor the duration o the injection treatment course. Tis is highly

discouraged due to the limited space in the MDR-B ward andthis option should only be pursued i absolutely necessary (Nurse3, Personal Communication, November 14, 2011). I observedthis phenomenon during one home assessment in a villageapproximately one hour rom the hospital. In a village locatedapproximately one hour rom the hospital, it was unrealisticto expect an injection nurse to deliver injections directly tothis patient due to the sheer distance. However, the patientshome was located several kilometers rom the nearest clinic, alocation that was simply not walkable. According to the patient,travelling to the clinic six times a week or our months to receiveinjections would be a R 1200 (USD 135) expenditure, a costthat was unaffordable (B Assistant, Personal Communication,

November 3, 2011). Te home assessor did not have a solutionto the situation and he stated that the only option was to keepthe patient in the MDR-B ward or a six-month period (BAssistant, Personal Communication, November 3, 2011).Scenarios like this demonstrate that it is necessary to weigh theprobability o patient deault against the personal and economicburden associated with six months o isolation in the MDR-Bward.

Te impact o the rural environment on MDR-Bmanagement was very apparent in other ways. As mentioned,homes are dispersed over a wide geographic area with no senseo organization. Many o the homes are makeshif or inormalhuts with no address (See figure 1). As such, it is imperative that

those involved in the treatment and surveillance o MDR-B inthe community are amiliar with the area and can locate the manyhomes ound only by driving down unmarked dirt roads throughdense bush and shrubbery (See ). Various landmarks like trees andrivers were the only means o distinguishing specific locations.Tereore, amiliarity with the terrain is a must or health workersin rural areas. Another obstacle posed by the rural setting liesin linking patients with DO supporters. Ideally, all MDR-B patients would be linked with a community health worker,nurse, or other medical personnel or the provision o directlyobserved treatment. Because healthcare workers are amiliarwith the severity o MDR-B and the importance o complianceto treatment, they are very effective as DO supporters [4].However, due to the remote location o many rural homes and thelack o healthcare acilities in such an environment, it is simplyimpossible to link all patients with a healthcare worker or DOsupport (Nurse 2, Personal Communication, November 14, 2011).Tereore, amily members have emerged as the only option ordirectly observed treatment. Based on these observations, it isimperative that the impact o a rural environment is consideredwhen implementing community-based programs or MDR-Bcontrol. Otherwise, the obstacles and limitations posed by arural setting could have disastrous effects or MDR-B healthcarepersonnel.

Conclusion

MDR-B is a complex problem placing a significant financiaburden on an already struggling healthcare system. In KwaZuluNatal, MDR-B has emerged as one o the most critical healthconcerns, and the incidence o new MDR-B cases over thelast several years is greater than that o any other South Aricanprovince [2]. Tere is a great need or medical acilities andpersonnel or the treatment and surveillance o MDR-B patientsas many MDR-B treatment centers remain overcrowdedunderstaffed, and simply unable to care or all inectious diseasepatients. Tereore, community support structures must be inplace to maintain patient adherence to therapy during the longand arduous treatment regimen. I the management o MDR-Bin the community is not a priority, patient noncompliance mayresult in the development o extensively resistant strains o B.

Tis project allowed or a comprehensive understanding

o MDR-B control in one rural community. Although someobservations may not generalize to all communities dealing withMDR-B, they can certainly be applied in a variety o settings. Alhealth personnel consulted or this project -- nurses, B tracersdoctors, and other health workers -- are essential in developinga community-based program or managing MDR-B. Teseindividuals are interconnected in a complex system o treatmenand control, and their importance cannot be understated. It iimportant that South Arica and other nations with a significanMDR-B burden invest in the training o these personnel inorder to manage this growing epidemic and prevent urthermorbidity and mortality. Experiences with these individuals havereinorced the point that MDR-B patients cannot be neglected

when they leave the hospital. Health personnel must take theproper measures to ensure that patients receive sufficient careduring the duration o their treatment including educationsymptom management, DO support, etc. Government healthauthorities must prioritize MDR-B diagnosis and treatmentand allocate sufficient resources to ensure that this epidemicis contained. Te successul management o MDR-B at thecommunity level is imperative in the global fight against B and icannot be neglected, especially in resource-poor countries wherethe burden is greatest.

Fig. 2. An example of a rural road in the Hospital X

catchment area. (Photo taken by author)

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4. Wagner B. Drug Resistant B Highlights Need or New Drugs to Battle

Disease. B Alliance. Oct 20035. Department o Health: Republic o South Arica. Multi-Drug Resistant

uberculosis: A Policy Framework on Decentralized and Deinstitutionalized

Management or South Arica. http://www.doh.gov.za/docs/policy/2011policy_B.pd. August 2011.

6. Singh JA, Upshur R, Padayatchi N. XDR-B in South Arica: No time odenial or complacency. PloS Medicine. 4(1): Jan. 2007 p. 19-25

7. Revised National uberculosis Control Programme. DOS-Plus guidelinesNew Delhi: Central B Division. Directorate General Health ServicesMarch 2006.

8. Te Management o Multi-Drug Resistant uberculosis in South Arica2nd Edition. Department o Health. June 1999.

9. Holtz H, Lancaster J, Laserson KF, et al. Risk actors associated withdeault rom multidrug-resistant tuberculosis treatment, South Arica19992001. Int J uberc Lung Dis. 2006;10:64955.

10. Partners in Health. DOS-Plus Handbook: Guide to the CommunityBased reatment o MDR-B. Boston, MA: Partners in Health; 2002Available at: www.pih.org.

Michael Celone will be graduating in May 2013 from Tulane University with a Bachelor of

Science in Public Health. He has already been to South Africa and Ghana and hopes to

work in East Africa for a year after graduating. In the future, he will pursue a Master of Public

health degree to explore his interest in neglected tropical disease control. In addition to his

academic interests, Michael enjoys African languages, Arrested Development, playing the

drums, and exploring the New Orleans music scene.