-Good afternoon ladies and gentleman. Thank you very much for inviting me to speak here today. I am very honored and grateful for this opportunity and hope that my talk will be somewhat interesting and informative for everyone here.
-My talk will be divided into four parts-I thought I would start off by talking briefly about my personal background to give you some context for my work and ideas.-Next, I would like to talk about my work with the Nick Simons Institute, particularly with one specific program—the Rural Staff Support Program—that I had the opportunity to work on. -Next, I would like to tell you about my recent work with an INGO called Nyaya Health which is operating a hospital in Achham, a district in far-Western Nepal. I would particularly like to share some stories from Achham to give you a sense of what life and medical care is like in rural Nepal.
-I was born in Kathmandu. My earliest experiences with health care in Nepal was in highschool through a small NGO called Social Action Volunteers , based at the only children’s hospital in all of Nepal. The NGO provided support in the form of housing, money for transportation and food to poor families, mostly from rural areas of Nepal, who came to obtain treatment at the hospital for their children. -After highschool, I was extremely lucky to get a scholarship to Yale for my undergraduate studies. I majored in Molecular Biology and one evening on Science Hill, while waiting for my second protein gel of the day to finish running, I began to think about when and how some of these breakthrough technologies at the frontiers of molecular biology research would ever be applied in the health sector of developing countries like Nepal. That thought led me to an internship in Geneva at the headquarters of the World Health Organization at the UNDP/World Bank/WHO Special Program on Tropical Disease Research--I focused on various projects related to tuberculosis, including examining the effects of social inequalities on the emergence of multi-drug resistant TB (MDR-TB). That same summer, I carried out research at the National Tuberculosis Program in Thimi, Nepal on the prevalence of MDR-TB within Kathmandu Valley. --After Yale, at Harvard Medical School, my interest in health care in the developing world was further fueled by experiences at the Harvard AIDS Institute in Botswana focusing on children affected by HIV/AIDS.--I also sought out opportunities for medical work at home in Nepal and was lucky to meet and work with Dr. Mark Zimmerman, the current Director of Nick Simons Institute in Nepal, while he was at Patan Hospital. I first heard about the Nick Simons Institute when it was initially being formulated. A few colleagues from the HSPH and I got together to write a report and do a literature review which helped to inform NSI in developing its initial concept document. -Currently, I am a resident in the Global Health Equity Program at the BWH in Boston.
-The Global Health Equity Program is a four year internal residency program (as opposed to the normal three years). I am currently in my third year in the program.-It was the brainchild of Drs Paul Farmer and Jim Kim, both renowned for their work with Partners in Health as well as Prof. Howard Hiatt, whom it is named for.-It is named for Prof Howard Hiatt, an exemplary figure in medicine and public health here in the United States. He was Dean of HSPH from 1972-1984, former chairman of the dept of medicine at BI, one of the first to describe the role of messenger RNA.-Through this unique residency program, I have had clinical experiences at Partners in Health sites in Haiti, Rwanda and Lesotho.-During my third and fourth year in the program, I can choose one country to focus on and carry out clinical and public health projects in. Because of my strong background and interests, I was allowed to expand beyond the PIH sites and work in Nepal.
-Now that I’ve given you some information about by personal background, I am going to switch gears and talk about NSI and my involvement with the Rural Staff Support Program
-First to give you some background for NSI’s work, there are tremendous gaps in healthcare in rural and urban Nepal For example, 96%of doctors in Nepal work in kathmandu valley (the capitol) while <10% of the population lives there.-Attendance at birth by a HCW specifically trained in carrying out births has been shown to improve outcomes for mothers and babies. Skilled birth attendance drops 4 fold from KTM to rural Nepal.
-Furthermore, as of 2008, only 13/67 district hospitals in Nepal had CEOC (meaning the ability to carry out C-sections), which is by far one of the most important determinants of maternal mortality.
It was in the setting of these rural/urban disparities that NSI was established in 2006 with a mission to train and support rural HCW by:-developing and providing quality training aimed at rural HCW-supporting rural HCW, providing an enabling environment in the field which would foster their retention in rural areas and ensure increased productivity-by providing scholarship to health care leaders, particularly MDGPs (general practitioners) who are most suited for practice in rural areas.
-My involvement with NSI started in October 2005 prior to its establishment-a group of my fellow MPH colleagues and I at the Harvard School of Public Health conducted a consultation (including literature review) that informed NSI in developing its original concept document.-Our report was entitled Train to Retain and one of the main interventions that we pushed for was increasing the number of family practitioners (a class of doctors that we felt were best suited for practice in rural areas and were more likely to stay there)-It is very satisfying for me to see some of the ideas we had proposed back then take frutition just a few years later
-One of the biggest problems with rural healthcare in Nepal, as with other countries in the world, even here in the United States, is the retention of health care workers. In Nepal, one of the first studies that NSI carried out looked at the actual staffing patterns at district hospitals—sort of a spot check of a third of the district hospital in Nepal and found that of the 50 who were recorded to be ‘in post’, only 39 (78%) were actually present at the time of the assessment. -In addition, of those doctors who were present, only 56% had been present on a full-time basis throughout the previous 12 months. Mid-level health workers were more likely to stay.-The reasons doctors don’t stay are multi-fold and reasonable—something that I understood better after having spent 2 months in Achham. Living conditions are not great, many communication problems (sometimes phones don’t even work), very unlikely that family would be able to come given lack of good schools in those areas. Very cut off from the rest of the world. No back-up in difficult cases. This lack of a doctor then leads to a viscious cycle of hospital under-utilization as patients come to the hospital, are disappointed that there is no doctor, go back to their homes and never come back.-To respond to this problem: One of the programs that NSI has developed to address its second mission (support for rural health care workers in order to foster their productivity and retention) is the Rural Staff Support Program composed of the 6Cs
-This is a basic package of interventions for struggling district hospital where there are no doctors and very few patients. -This program is composed of an integrated set of human resource supports characterized by the "6 C's": Communication which consists of an internet connection through a VSAT device depicted in the picture—through this, people can communicate even when telephone connections are poor. Connection with a larger center—so that the smaller, struggling hospital can learn from a larger, better functioning hospital, Continuing medical education through distance learning as well as training programs, Community-based hospital management (in extremely remote and rural areas, local communities are far better at monitoring and managing health care workers and health institutions than the central ministry of health based in far-away Kathmandu. By promoting community governance, we improve the staff retention and quality of care. Children's education—most doctors do not bring their families to rural areas when they are posted there because of a lack of good schools for their children. Trying to improve schooling in the surrounding communities may help to improve retention in the long term. At the very least, it will improve education in those areas for the local children. Captaincy by an MDGP doctor is perhaps one of the most important of the 6Cs. An MDGP doctor undegoes 3 years of training beyond the regular MBBS training. The training includes adult medicine, pediatrics, obstetrics and gynecology as well as a few key surgeries like c-sections, appendectomies and hernia operations.-The three principle outcomes of this program are that each district hospital will undergo (1) an increase in patient utilization, (2) an increase in district hospital curative care training of that district's health workers, and (3) upgrading of the hospital's emergency obstetric care (EOC) service status. -The RSSP project is initially being piloted in three district hospitals in Bajhang, Gulmi, and Dolakha.
-In May 2007, I had the opportunity to work with the Nick Simons Institute on the Rural Staff Support Program in terms of outlining a way forward.-I was assigned the task of finding lessons that NSI could learn from similar programs carried out by the Nepal Safe Motherhood Project and by UNICEF at rural district hospitals.-Further, I explored what would be feasible, what would work and what wouldn’t within the RSSP program. One of the other questions to be answered was whether RSSP would be a good use of NSI’s resources.
-In order to answer these questions, I conducted site visits and interviews at various hospitals throughout Nepal, with a focus on the far-Western part of the country.
-point out districts/hospitals visited
--One of the main conclusions that I came to from these site visits and interviews was the question: What is the output that NSI seeks? Is it simply to train health care workers for rural Nepal or is it to actually improve the health of the people of rural Nepal?--What I found when I spoke to health care workers at these hospitals was that although they wanted more training, they had had a lot of training. They had gone on various training programs for TB, COPE (counsellingtraning), IMCI training, etc. But, there was a major disconnect between actually obtaining training and using that training on the ground in their work. Sometimes, there were major disconnections between who went on training and who would actually use that training in their daily work. For e.g. ANM (auxilary nurse mid-wife with leprosy training).--I think it is very important that training go hand in had with concrete health care service delivery.--The RSSP perfectly fills this role because it allows NSI to directly impact the delivery of health care rather than simply training of health workers. As Mark Zimmerman accurately states, RSSP is essentially a hands-on laboratory for NSI to continually learn from experiment with.
-An important component of RSSP, although not directly included in the 6Cs is infrastructure support which includes physical facilities, equipment, medication and supplies.--For what good are well trained staff without proper equipment to do the things that they are trained to do?--I recommended a detailed needs assessment in each pilot RSSP district initially focusing on obstetric are (for e.g. is there a functional OR, do they have supplies for C-sections?--I think that over time, other areas of need should be focused on in addition to obstetric care--A huge area of need particularly in remote areas such as the far-West is logistical support for pharmaceutical and other supplies--All of these things will help to create an “enabling environment” for the MDGP doctor and other staff so that they have the tools with which to carry out their work
-A large component of UNICEF’s work at the district level was community based. The Community Based Safe Motherhood Project, which helped to create a demand for hospital-level obstetric services, was initiated prior to the WRLHI, which subsequently focused its efforts on improving quality of care at hospitals. -In the future, NSI’s Rural Staff Support Program will be more effective if it develops programs focused not just on the district hospital but on lower, community level centers like the primary health center and health post. Use of community health workers to create demand…
-Since May 2007, RSSP has been progressing at a slow but steady pace. -Gulmi currently has an MDGP doctor who has set up an OR is carrying out c-sections at that hospital-Bajhang will have an MDGP within the next 6 months-Jiri should also have an MDGP in the next year.-All three places have Communications/VSAT set up. Most of the 6Cs are thus underway.-I plan to work with NSI over the next year on the formulation and implementation of site standards and strengthening of M+E component of the program
I am going to switch gears now and talk a bit about my involvement with an INGO called Nyaya Health based in far-Western Nepal in a district called Achham. Before I move on, are there any questions about RSSP?-If you remember, one of the hospitals I visited during my work with RSSP was Bayalpata Hospital in Achham which at the time, was a non-functional hospital—essentially a bunch of abandoned buildings.
-point out far-West and Achham
Location of Saanfebagar/Bayalpata
--Drawn to working in the far-West after having seen conditions in Bajhang/--I also wanted to carry out clinical work in a rural setting in Nepal. Had only worked in a clinical capacity as a medical student at Patan Hospital in Kathmandu. Wanted to understand the ground realities of conditions in the far-West.--Learned about a young group of medical students and residents who had started a clinic in Saanfebagar, Achham. Nyaya was started by a young group of medical students in response to the dire needs in Achham, main principles of the organization which I was drawn to—transparency, use of technology, essentially 99% of funds reaching Achham (no office in Kathmandu, no overhead costs b/c it is essentially all volunteer run)
Constructing effective healthcare facilities requires planning and community involvement. COVER POINTS ON SLIDE
Bayalpata hospital is the big next step that Nyaya has undertaken to build the health system in Achham. The hospital is opened on 21 June, 2009.Story of Bayalpata Hospital—political dispute—never opened. Just like the Maternity Ward in Bajhang, buildings built, millions of dollars spent on building and maintenance costs, 30 years of inactivity.
Human resources form the core backbone of a health system. Additional point re: physicians: In Nepal, the overall physician: citizen ratio is 1 in 70,000; in Kathmandu, the capital city, that number is 1:5,000. In Achham, prior to the arrival of Nyaya Health, it was 1:500,000
Close up view of the hospital buildings which are fairly well-preserved from the outside
A view from the staff quarters
-There were a few themes that recurred during my two months in Achham that are illustrative of the social and health situation there. These include severe gender inequality, the difficulty of life in the hills, the acceptance of death by the community and the difficulty of referrals to a higher level of care. I am going to share with you a few patient stories that illustrate these themes.
-I was quite shocked by the level of gender inequality in Achham. -When you asked patients how many children they had, it was very common for them not to count the girls. You would find out later in the conversation that they had 3 girls in addition to the two sons they mentioned.-It was also fairly common for parents to take their sons for further treatment (for example if they needed to be referred to a tertiary hospital) but not the daughter.-When I saw pregnant women in the antenatal clinic, I was surprised at how many of them reported a condition called pica or geophagy in which they are compelled to eat mud. This brings to light the levels of iron deficiency that these women must suffer from. The mud or clay provides them with iron and other nutrients.-Literacy rates in Achham are dismal, particularly for females and the level of disparity is astounding
-This was a 13 year old girl I encountered on my trip to Mangalsen—the district headquarters. She had never been to school. She’s holding a hasiya (a sickle) in her hand for cutting grass—she was collecting fodder for the animals, a task that she spends most of her day doing.
Many young girls are also busy taking care of younger siblings like this one.
--I had a particular patient encounter in the outpatient department which really gave me a sense of the levels of gender inequality in Achham. --These are excerpts from an article I wrote about the situation.--she was a middle-aged woman who approached me very timidly in the outpatient department.--ultrasound--neighbors and other extended family members --health aide who works at the hospital who also went to India to have an abortion (husband said he would divorce her if she does not have a son)--many pregnant women just coming for an ultrasound for sex determinationWearing a red and green sari, a fulli in her nose, a fair, middle-aged woman approached my desk in the Outpatient Department very timidly. Averting my gaze, she turned her eyes to the floor and spoke softly, not wanting anyone else in the room to hear. “I have seven girls. I had one boy but he died when he was very young. I’ve been to Dhangadi two times before but both times they were girls and I got rid of them.” On further questioning, she revealed that she had not menstruated in four months. She thought that she may be pregnant again and wanted to know if it was a boy or a girl. If it was a boy, she would keep it. If it was a girl, she would abort. Her husband was an auxiliary health worker in a neighboring village and was understanding; he loved his seven girls. But, the neighbors and extended family members would have their say with her whenever the opportunity arose. She was sick and tired of hearing that she was a useless wife who could not produce sons. Sometimes, these people would even tell her husband that he should marry another wife. Last year, when she had gone to Dhangadi, she and her husband spent almost Rs. 40,000 on medical treatment. In the Indian town of Paliya which borders Dhangadi, she underwent three ultrasound examinations to try to see the sex of the baby before it was finally confirmed that it was a girl. The rest of the money was spent on a D&C to abort the female fetus, along with travel and room and board. She had heard through other villagers that Bayalpata Hospital has a “video-xray” (the term for an ultrasound in these parts) and thought she would just come here to find out the sex of the baby for she knew services were free. Her urine pregnancy test did turn out to be positive. Amid much protesting from her, we had to tell her that we do not use our ultrasound to tell patients the sex of their baby. If she wanted to keep the baby, whatever sex it was, we would provide her with appropriate antenatal care. If she did not want to keep the baby because she felt she had had enough children, we could provide her with comprehensive abortion care as long as the fetus’s age was within 12 weeks. Despite an hour of counseling, she left saying she would now have to go to Dhangadi again for an ultrasound. At Bayalpata Hospital, encounters such as this are quite common. Many of the pregnant women that come to the hospital come knowing that we have ultrasound services and can perhaps tell them the sex of their baby. Counseling such women at their visits seems futile in a society where the male child is so highly valued. Unless the status of women as a whole improves throughout Achham, women who have the means, will continue to make the long journey to Dhangadi and India.
These are pictures of two deliveries we had at the hospital within a few hours of each other, one was a boy and one a girl. Unfortunately, the difference in the level of joy expressed by family members is quite noticeable when you mention that the baby is a girl versus a boy.
-Another recurring theme that I personally experienced was the difficult of life in the hills
How difficult it is to find transportation—many jeeps unwilling to take patients for fear of what will happen along the road.
--Death is the ultimate epidemiological truth.-acceptance of death-one of the most difficult parts of the whole experience in addition to a little girl dying unnecessarily was the ease with which the family accepted the death—as though it was just a part of life. On arrival, she had very labored breathing with a RR in the 70s and severe chest retractions, HR in the 170s and O2 sat in the high 80s. She also produced a large amount of coffee ground-like vomitus. Her physical exam was notable for a pediatric Glasgow coma scale of 8, reactive pupils, crackles and rhochi mid-way up her lung fields. No notable neck rigidity or skin findings. Within an hour of arrival, she had a seizure characterized by clenching of her teeth and tonic-clonic movements of her head and arms. She was treated for presumed meningitis/encephalitis with Ceftriaxone, Dexamethasone and Diazepam for seizure control. She was also started on IV fluids and given oxygen. At approximately 4pm, the on-call ANMs took her vitals and noted that she was doing a little bit better. Her RR had slowed down to the 60s, her O2 sat was 92% and her pulse was in the 150s. However, around 4:20pm, family members called for the nurse because the child was no longer breathing. On assessment by a physician, the child was pulseless, without breath sounds and did not have a corneal reflex.The child was from the village of Budakot which is about 4 hours away from the hospital. She lived with her mother and 4 siblings. She was the youngest daughter in the family. Her father was away working in India. She was from the Dalit community.Final EvaluationThe primary systems issue that contributed to this tragedy: 1) lack of community health care and education 2) lack of ICU level care in Achham 3) difficulties of referral
Elderly female with severe pneumonia—someone who would have been intubated, on a ventilator in the intensive care unit in the US. Relied on clinical exam for diagnosis—RLL pneumonia. No X-ray. Improved with IV antibiotics, nebulizers. Child with diarrhea
This slide is an outline of the aspects of Mission #2 Developing a Scalable Model we will now discuss.
Nyaya Health has all financial information publicly available on our wiki to ensure full transparency. Our team has extensive experience in the non-profit sector, and a key compomnent of Nyaya's mission is to advocate for increased transparency throughout the global health community. Nyaya's wiki offers us an easy and readily exportable model to achieve further transparency in this type of work.
-No real concept of CME at the hospital/ in Nepal-Lecutures from 3-4pm three times per week
IMPORTANT CHALLENGES/NEXT STEPSThis is a good place in the presentation for an updated slide discussing particular needs.- significant needs at the hospital but the group is doing as much as it can with the resources that it has-
Ruma's simons foundation talk 112809 final
From the Brigham to Bayalpata<br />RumaRajbhandari MD MPH<br />Global Health Equity Resident<br />Brigham and Women’s Hospital<br />
Personal Background<br />Born in Kathmandu<br />Social Action Volunteers<br />Yale University, Molecular Biology<br />World Health Organization, National TB Program<br />Harvard Medical School, Harvard AIDS Institute in Botswana<br />Patan Hospital/ Nick Simon’s Institute of Rural Health Care Training<br />Brigham and Women’s Hospital, Global Health Equity Residency Program<br />Nyaya Health, Bayalpata Hospital, Achham<br />
Global Health Equity Residency<br />Doris and Howard Hiatt residency in Global Health Equity<br />Paul Farmer, Jim Kim, Partners in Health<br />Extra year of internal medicine residency<br />Clinical experiences at PIH sites: Haiti, Rwanda, Lesotho<br />3rd and 4th year: Nick Simons Institute/Nyaya Health<br />
Background situation<br />Wide gaps between urban and rural health care in Nepal<br />Rural U5 mortality: 84/1000<br />Urban U5 mortality: 47/1000<br />Doctor density drops 30-fold (96% of doctors in Nepal work in Kathmandu valley (<10% of the population lives there)<br />Skilled birth attendance drops 4-fold from Kathmandu to rural Nepal<br />
Nick Simons Institute of Rural Health Care Training<br />Established in 2006 with a mission to train and support skilled, compassionate rural health care workers through:<br />the development and provision of quality training programs <br />support for rural health care workers in order to foster their productivity and retention<br />scholarships for health care leaders, particularly MDGPs <br />
Involvement with NSI<br />Harvard School of Public Health project (October 2005)<br />“Train to retain”<br />Increasing the number of rural family practitioners<br />Rural Health Care Workers conference<br />
Rural Staff Support Program<br />Study of actual staffing patterns at district hospitals<br />56% doctors present on full-time basis throughout the previous 12 months<br />Rural Staff Support Program (May 2007)<br />Part of NSI’s second mission to support rural health care workers<br />Composed of the 6Cs<br />
RSSP: Developing a way forward<br />May 2007<br />To find lessons that NSI could learn from similar programs e.g. NSMP, UNICEF<br />What is feasible, what will work and what won't? What else should the RSSP program include? Is RSSP a good use of NSI's resources?<br />
Site visits and interviews<br />Site Visits and interviews at district hospitals<br />Gorkha District Hospital<br />Lamjung Community Hospital: Tripartite agreement between MoHP, local NGO and HDCS<br />Dolakha District Hospital, Jiri<br />TEAM Hospital, Dadeldhura: Christian mission hospital<br />Bajhang District Hospital, Chainpur<br />Bayalpata Hospital, Accham: at the time, non-functional hospital<br />Su-joon Hospital, Doti: Korean mission hospital<br />Dadeldhura District Hospital <br />
Rural Staff Support Program<br />Training must go hand-in-hand with health care service delivery. <br />Allows NSI to directly impact the delivery of health care <br />Hands-on “laboratory” for NSI <br />
Infrastructure support<br />Well trained staff need proper equipment to do the things they are trained to do<br />Detailed needs assessment in each pilot district, initially focusing on obstetric care<br />Creating an "enabling environment" for the MDGP doctor and other staff<br />
Community based health care<br />Initial focus of RSSP is on the district hospital (supply side)<br />Community-based health care (demand side) important<br />Partners in Health: community health workers are key <br />
Progress of RSSP<br />Gulmi: MDGP doctor, functioning OR<br />Bajhang: MDGP doctor within the next 6 months<br />Jiri: MDGP in the next year<br />Future projects<br />Site standardization<br />Monitoring and evaluation<br />
Community Health Workers (CHWs) </li></li></ul><li>Staff Recruitment<br />Focus on local talent<br />Salaries on par with the Nepali government <br />Opportunities for career advancement<br />27<br />
Recurrent themes<br />Severe gender inequality<br />Difficulty of life in the hills/ Natural “disasters”<br />Acceptance of death<br />Difficulty of referrals<br />
Severe Gender Inequality<br />Girls not counted among children <br />Taking a son for further treatment/referral but not a daughter<br />Pica/geophagy (eating mud)severe iron deficiency<br />Literacy<br />
Illegal abortion of female fetuses <br />“I have seven girls. I had one boy but he died when he was very young. I’ve been to Dhangadi two times before but both times they were girls and I got rid of them.”<br /> <br />If it was a boy, she would keep it. If it was a girl, she would abort. <br />Last year, when she had gone to Dhangadi, she and her husband spent almost Rs. 40,000 on medical treatment. In the Indian town of Paliya which borders Dhangadi, she underwent three ultrasound examinations to try to see the sex of the baby before it was finally confirmed that it was a girl. The rest of the money was spent on a D&C to abort the female fetus, along with travel and room and board.<br /> <br />
Difficulty of life in the hills: Natural “disasters”<br />Difficulty of life in the hills<br />1-2 hour walk to the hospital considered convenient<br />Patients carried on the back in a dokoor on stretcher for days to reach the hospital<br />Mangalsentrip—10 hours<br />Natural “disasters”<br />Damage from a single day of rain <br />No electricity, no supplies, no water<br />
Referrals<br />What disease/ill health means for a family especially when they have to be referred<br />Jeep ride to Nepalgunj/TEAM Hospital<br />Cost of medicines, hospital bed, operation, room and board<br />Treating a simple illness means going into major debt<br />
Develop a Scalable Model <br />Developing a scalable model is central to building the field of global health delivery<br />Nyaya Health uses several tools:<br />Wiki<br />Blog<br />Data monitoring and evaluation<br />Open-access clinical and financial data<br />51<br />
Developing a Scalable Model: Data Monitoring<br /><ul><li>Effective healthcare driven by data monitoring and evaluation
Collaboration between Nepal- and US-based data team is critical:
Public access to enhance collaboration and transparency in the global health community
Revision of programmatic design and protocols according to regular data evaluation
Rigorous attention to patient privacy http://wiki.nyayahealth.org/DataManagement</li></ul>52<br />
Developing a Scalable Model: Financial Transparency<br />Nyaya’s wiki offers ready accessibility to:<br />Line-by-line expenditures<br />Month-by-month budgets summaries<br />Accounts balances<br />Benefits<br />More engaged donors<br />Organizational culture of honesty and openness<br />More effective management<br />http://wiki.nyayahealth.org/Budget<br />53<br />
CME program<br />NSI Mid-level practicum<br />CME for mid-level health workers at Bayalpata<br />Interactive lectures tailored for mid-levels<br />Dubbed in Nepali<br />Lectures from 3-4pm three times/week<br />
Nyaya Health: Future Plans<br />Furnishing/renovation<br />X-Ray services <br />Surgical capacity (C-sections)<br />Larger community health worker network<br />Expanded energy systems<br />HIV treatment center<br />55<br />