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| CAN YOU SOLVE THIS CASE OF MALNUTRITION? |
The two-year old child in this photo presents to your health center in the Democratic Republic of the Congo. Family members explain that eight months ago their farm was attacked by bandits. No one in the family, including this child named Aamir, has eaten regularly since then. What's more, Aamir in recent days has developed fever, diarrhea and lethargy.
On initial physical examination you note that Aamir is poorly responsive to stimulation. His temperature is thirty-eight degrees C, respirations are thirty per minute, pulse is ninety, and blood pressure is unobtainable. He has extreme muscle wasting throughout and loss of adipose tissue but no peripheral edema. Aamir's measurement of mid-arm circumference and skin fold thickness are well below the norms. Your diagnosis is marasmus. This year, would you like to take action on behalf of children like Aamir? Begin by arming yourself with the necessary knowledge and skills. Join us in June for the INMED International Medicine Intensive Course and INMED International Public Health Intensive Course. Also available this September for the first time: the INMED International Medicine Intensive Online Course and INMED International Public Health Intensive Online Course. Be prepared when you care for a child like Aamir. |
| CAN YOU SOLVE THIS CASE OF TROPICAL FEVER? |
The seven-year old girl, Maria, in this photo presents to you at the Clinical Evangelica Morava on the remote western coast of Honduras. Her parents explain that five days ago she suddenly developed fever, vomiting, severe headache, and pain on moving her eyes. Several other children in the neighborhood have been similarly ill since the onset of the rainy season with its customary heat and mosquitoes.
On physical examination you note that Maria is lethargic, has generalized lymph node enlargement with clear lungs and a slow heart rate relative to her fever of 39 degrees. She has a fine rash on her extremities. You quickly perform thick and thin blood smears with Giemsa stain but you do not identify any ring-like Plasmodium parasites within red blood cells that would suggest malaria. Your initial differential diagnosis is broad: influenza, dengue, typhoid fever, mononucleosis, malaria with negative blood smear. You initiate intravenous fluids and antipyretics. Over the next hours Maria develops hypothermia, severe abdominal pain, persistent vomiting, decreased mental status, and bleeding from her gums and nose. You now suspect the Maria is suffering from dengue - an arbovirus infection. Dengue fever is a classical disease of poverty - one associated with insects and poor housing, and one that calls for broad social development as well as medical interventions. The heartening response of many to Maria's illness is to offer their personal time and talent to rescue those like her. But even well meaning rescue has its limitations. The 2011 INMED Exploring Medical Missions Conference theme is From Rescue To Resilience. Please join us for this event as we emphasize 'training the trainers' - equipping participants to in turn empower leaders of marginalized communities to combat poverty and to care for their own. |
| CAN YOU MANAGE THIS POSTPARTUM HEMORRHAGE? |
The seventeen-year old lady, Adriana, in this photo presents to the maternity ward at the Lubango Evangelical Medical Center in Angola, southern Africa. Her last menstrual period is unknown, but her uterus is full-term in size. She is in labor and shortly delivers a healthy infant, followed by delivery of her intact placenta.
One hour later you receive a call from the maternity nurse urging you to come quickly. On arrival, Adriana is conscious but her systolic blood pressure is 80, and her pulse is 140 and weak. Clots of blood are flowing from her birth canal. Adriana's hemorrhage rapidly resolves. You sense a deep satisfaction over not only preserving her life, but realizing that next time the maternity personnel will be better capable of handling this crisis without outside assist. We must move beyond simply providing care, onward to equipping others to care for their own. INMED is devoted to protecting mothers and newborns through multiplying skilled individuals. Two upcoming learning opportunities are the INMED International Medicine Intensive Course and INMED International Public Health Intensive Course. Join the ranks of those assisting local people to protect women like Adriana! |
| MAKE A LASTING CONTRIBUTION: TEACH YOUR SKILLS |
"This woman is in labor, but the baby just will not descend!" Dr. Akua spoke anxiously and with good reason. He'd just graduated from medical school in Ghana and only yesterday joined me at the Baptist Medical Center in northern Ghana to begin his years of public service. We examined the lady, found her contractions to be strong and the baby in good position. "She looks safe for the moment," I said. "Let's recheck in 2 hours."
Each year some 5,000 teams leave the United States to provide healthcare in developing nations. Most of these trips are for 1 to 2 weeks and provide episodic care. One most commonly expressed frustration of participants is that once they depart the host community, little continuity of care is available to the people whom they served. How can we contribute to lasting care and progress in the world's most impoverished communities - like sites in northern Ghana, urban India, or rural Papua New Guinea? This is the theme question of the May 20-21 INMED Exploring Medical Missions Conference. Clearly our efforts to support basic literacy and economic development are foundational. In the realm of providing direct medical care, consider what happened next in Ghana... "Dr. Comninellis," exclaimed Dr. Akua, "I examined the woman again. The baby is still not descending." I verified his exam and agreed. "Akua, how should we manage this complication?" Akua's voice grew quite serious. "Oh doctor, you must perform a Cesarean right away." I shook my head. "No Akua," I replied, "YOU must perform the Cesarean." Akua's eye grew very large. "Doctor, I have never witnessed this surgery." "Yes, but when I leave just ten days from now, you will be the only physician at Baptist Medical Center . It's time for you to learn!" One-hour later mother and baby were fine following Akua's successfully-performed operation. Throughout the following week we managed several complicated patients in labor, and Akua's surgical and decision-making skills steadily rose. And today he is still caring for his own people in Ghana. Equipping local citizens is one of the most effective ways to make a lasting improvement on communities in distress. Several reputable programs are doing just this:
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| ARE SHORT-TERM MEDICAL MISSIONS EFFECTIVE? |
"In Haiti over eight days we saw 900 patients, treating infections and diarrhea. The people are desperately poor and were so very grateful for the medical care." Anna, a family physician, spoke with enthusiasm. Then her voice turned somber. "But people also came to us with diabetes, asthma, and convulsions. We gave them a small supply of meds, but they can never afford ongoing treatment. What will happen to them?"
Anna's frustration is shared by thousands of healthcare professionals who engage in short-term medical missions (STMM) each year. Their altruistic motives are often tempered by the reality of daunting questions. In fact Controversies In Short Term Medical Missions is one of the most often requested breakout sessions for this May's Exploring Medical Missions Conference. We would like to solicit your thoughts about the most common dilemmas facing those engaged in STMM. Next month we'll share some of your opinions with the 46,000 people who receive this newsletter. Regarding Anna's dilemma above, how would you as a STMM participant respond to the need for providing continuity of care for low-income people with chronic illnesses? Post your comment on the INMED Facebook Group or email your comments to office@inmed.us  
"Our team worked in Honduras for a week focusing on health of school children connected with a parish," explained Rachel, a pediatrics nurse. "Parasites penetrate the kids feet, and they are all are infected. We administered de-worming medication to the children. But then they walk home through the open sewage, where they'll surely become re-infected." Consider Rachel's situation. How would you in the context of STMM address prevention of common infections, malnutrition, or injuries? Post your comment on the INMED Facebook Group or email your comments to office@inmed.us
"Our team traveled to the northeastern region of South Africa, where almost every other person is HIV positive." Stanley, a public health specialist, expressed high hopes for their two-week journey. "I designed a presentation about sexual abstinence and condom use, and I gave it to several church groups. They all listened politely enough. But later, an elder quietly explained to me that males are expected and instructed to initiate sexual activity before even reaching their teen years. How can I be an effective educator when I know almost nothing about sexuality in their society?" Think about Stanley's situation. How would you recommend STMM become more culturally relevant to the particular views and needs of the communities we wish to serve? Post your comment on the INMED Facebook Group or email your comments to office@inmed.us
Thank you for sharing your insights! And please join us at the Exploring Medical Missions Conference as we together investigate how to make STMM more culturally relevant and effective over the long term. |
| YOUR SUGGESTIONS TO MAKE SHORT-TERM MEDICAL MISSIONS MORE EFFECTIVE |
In May's INMED newsletter we posed the question, "Are short-term medical missions (STMM) effective?" and also raised related issues of ethics and cultural relevance. Responses from you the readers were plentiful and absorbing.
You said that we should recognize both the pros and cons of such service: Advantages for our mission hospital are: Coverage for staff vacations, teaching our personnel new skills, giving us fresh perspectives, and providing of a service, like eye and hearing care, that we're not able to. There are disadvantages, too: The logistics of visitors can be draining (transportation, housing, interpreters) and they may raise expectations of our community for extra services that we can't sustain. - Nancy Cutherell, RN, Bach Christian Hospital, Pakistan STMM are great for the participants, bring them face-to-face with the plagues of deep poverty. Short-term volunteers become prayer partners, sometimes become longer-term workers, and help publicize our work so that others become supporters. They are also less likely to engage in quickie solutions to complex, multifaceted problems like the issues surrounding sexuality. - Jean Young, MD, Saboba Medical Center, Ghana You also recommended that the emphasis of most STMM change from provision of episodic care toward contributing to sustainable solutions: STMM should focus on those most at risk: women and children under five, and on programs most likely to result in permanent change: home gardens for family sustenance, growth monitoring for low-weight children, women's education, non-profit small loans for business startup, support for exclusive breast feeding. - Nicholas Cunningham, MD Dr PH, Columbia University Add value. Don't just come to do what the national staff is already doing. Train, mentor, encourage. Serve - but moreover build capacity. The most useful thing you will do is to train a local resident to continue providing a skill long after you have left. - Ian Chadwell, Partnership Program Manager, International Nepal Fellowship Such emphasis on sustainability is an integral part of the INMED International Public Health Online Course coming up in September and October. Many respondents resonated with the importance of developing and sustaining partnerships with host communities and institutions: To make a real change and contribution STMMs should be a part of an ongoing program to support particular hosts. Groups cannot visit a different location every year and expect to make a real change. We advocate providing continuity and expertise. In short, we should focus our efforts. - Doyle Word, CEO, Madaktari Africa If the leaders have a long-term vision, and each short-term team is only one part of that vision, then longer-term results can be achieved. To make this a reality requires being in partnership with an indigenous, local host in the community being served. In this context we help equip and encourage them, for in the long run lasting results are only achieved when the indigenous partners take the initiative to provide the long-term benefits themselves. - William Walker, COO, His Healing Hands What does healthy partnership with host nationals look like? Such partnership embodies the virtues of respect, humility, and deference toward others. In this context, we can inquire, "What can I do to assist at your facility?" "What special services do your people need?" "What subjects can I help to teach?" and perhaps most profoundly, "What can you teach me to better serve your people?" |
| RELIEF FOR THE WORLD'S URBAN POOR? |
Worldwide the number of urban poor is increasing steadily throughout Asia, Latin American. Emanuel lives in one such shantytown that surrounds the city of Lubango in Angola, southern Africa from where I'm writing at this moment. Emanuel's family is in crisis. His youngest child Elena, three-years old, started vomiting and passing bloody diarrhea. Her two older siblings began shivering from high fever. Emanuel 's wife, disfigured and disabled from polio, attempted to get next to and comfort them by sliding her body across the dirt floor of their one-room, tin roof house.
Emanuel, desperate to find treatment for his children, entered the dense neighborhood of shoddily-built homes, separated by footpaths and streams of tainted water. Emanuel went first to the pharmacy, but was turned away. Caring for his sick kids, Emanuel has not worked in five days and had no money to purchase medicine. He next stopped at the local dispensary, but found it boarded up. Emanuel, empty handed, reentered his congested community, passing neighbors who described with alarm how fever and diarrhea are spreading among their children, too. Late in the afternoon, Emanuel arrived at the Lubango Evangelical Medical Center - an INMED Training Site - where a compassionate staff treated little Elena's dysentery and controlled her sibling's malaria. But stopping acute disease alone is never sufficient until prevention is also addressed. Relief for the urban poor requires comprehensive improvements. INMED is fully committed to equipping individuals in the healthcare fields to play an active role. The September-October INMED International Medicine Intensive Online Course and INMED International Public Health Intensive Online Course are convenient ways to increase your own potential to assist the urban poor to attain sustainable progress and to help assure the Emanuel family never again faces such a crisis. |
| YOU CURSED MY BABIES! |
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"You cast a spell on my babies, Doctor. Surely my babies are going to die! Your envious, evil eye, it discloses the wickedness of your heart!" She pulled her twins tight against her chest. "You are an agent of the Devil," she spewed.
I was stunned at the young Hispanic mother. We were just wrapping up a routine one-month newborn checkup. I found both babies to be vigorous, nourished, and each child wearing a charm bracelet. With an expression of exasperation, I asked the mother, "What did I do wrong? Why do you believe I cursed your babies?" 
She fired a distrusting glance at me. "Doctors should know better! You gushed over how adorable are my newborns, and you probed their bodies. But nothing more!" With that the mother stormed out of the exam room. I looked on in shock and disbelief at the cross-cultural meltdown that just transpired, and I am not alone. A recent survey of physicians who participated in the Healthy Families program found that 71 percent of providers believe that culture and language are important in the delivery of patient care. 51 percent believe that their patients did not adhere to medical treatments as a result of cultural or linguistic barriers. The challenge of cross-culture and language barriers is a daily reality for us in healthcare. Fortunately in this instance, a nurse practitioner, Helena, also of Hispanic origin, came to my side. "Don't you understand why the mother is upset?" She queried. "I am simply clueless," I defended, "I was just providing a normal well-child check." Helena shook her head. "Did you complement the mother about her babies?" "Of course," I responded, "I expressed how lovely they are." "But did you touch them fondly?" Helena continued. "Touch them fondly? No, of course not." I said. "I'm a doctor. It's my job to examine them." Helena declared, "You have so little insight into our culture, Dr Comninellis. A touch of tenderness is necessary to communicate genuine affection. Without the touch, you are only expressing jealous envy. You are communicating that you wish the babies were your own or that they would die." Again I was shocked at her observation. "So how can I learn such intricacies about people of your culture?" I inquired. Helena's response was more sympathetic. "You begin with a keen awareness that cultures are indeed powerful. You and this Hispanic women are from very different worlds." I nodded in hearty agreement. "Next," she continued, "you observe and seek to understand those differences. Allow extra time to ask Hispanic people their views about health. This will also build confidence and rapport between the two of you." "And then?" I persisted. "Then," replied Helena, "you can adjust your care accordingly. For example, next time you provide a well-child check up, do not only complement the children but pat and stroke them tenderly in their mother's presence. This will convey your genuine admiration and dispel any suspicions." Vietnamese, Afghans, Somalis, Nepalese, Haitians, Native Americans...Do you find it challenging to provide effective health care to patients who are culturally distinct? Apply the process of observing, understanding, and adjusting to cultural differences. And sharpen your skills further by joining me for the 2011 INMED Cross-Cultural Healthcare Symposium on October 14. Together, let's progress beyond offering just quality healthcare and on toward providing culturally appropriate care. |
| I DEMAND THE WITCH DOCTOR, NOT YOU! |
"The kid's been seizing for an hour, but the dad won't let us give anything. No drugs, no oxygen. This kid's gonna die!" The paramedic's speech was pressured. "He's turning blue and the convulsions have not stopped since I picked them up in the shopping center parking lot. What else could I do?"
The ambulance had just screeched to a stop in front of the urban emergency department where I was on duty. Summoned to the driveway, I saw the paramedic fling open the rig's back door, revealing a dark-skinned man in his thirties clutching a preschooler. Initially limp and lifeless, the child suddenly began twitching his hands. The force grew stronger, encompassing his upper arms and shoulders. His thighs began jerking violently, and his back arched into a wicked contortion. The father struggled to maintain the child on his lap. He glared at me, "No white man medicine can help my child! He is afflicted by a dark spirit. It must be expelled by, how you say, a witch doctor." The father's gaze was cutting, and he continued with a heavy accent. "You know NOTHING of spirit world. How could you help? I demand the witch doctor, not you!" Conflicting views over health and healing are especially common when we care for people of dissimilar cultures. When crisis strikes, the resulting peril can be especially grave. What's the allure of witch doctors and other traditional healers? For one, they usually prescribe "natural" treatments that seem less invasive, including herbal medicine, nutritional therapy, and physical therapeutics. It is no wonder that even 'modern people' continue to seek out such elements of care. Traditional healing is also attractive because it often seems more holistic and integrated with one's local culture. The book The Spirit Catches You and You Fall Down explains, "For the Hmong people of Southeast Asia medicine was religion. Religion was society. Society was medicine... In fact, the Hmong view of healthcare seems precisely the opposite of the prevailing American approach, in which the practice of medicine has fissioned into smaller and smaller sub-specialties - isolated from society as a whole." I climbed into the back of the ambulance, positioning myself next to the reluctant father and jerking child. I inquired in an empathetic tone, "Do you known a traditional doctor among your people?" The father seemed cautiously intrigued. "Yes, he is foreigner like us." "Then please allow me to treat your child," I suggested, "while we also summon this healer to come to your son's aid here at the hospital." The father seemed relieved and relented. "You still know nothing of my people, but our doctor, he can teach you." Iraqis, Indians, Romanians, Phillippinos, Africans... How can we provide quality care to those like this father and son whose view of healing contrasts so greatly? Let's begin by extending an invitation to learn from them. Please join me for the 2011 INMED Cross-Cultural Healthcare Symposium on October 14 as we polish our social skills on behalf of children in crisis and parents in anguish. |
| I FORBID YOU TO INFORM MOTHER OF HER CANCER! |
"Why would you take away her last hope? If you tell my mother about the metastatic colon cancer she will die immediately! That would be cruel and I forbid you!" Luping's son and I spoke in low voices just outside her hospital room. He continued, "I brought my mother to America to receive the very best medical care, and now you want to tell her there's no cure? We would NEVER do this in China!"
I glanced in Luping's room, where the elderly lady was alert but fragile and clearly in pain. I turned back to her son. "But this is America," I explained, "Here the rules are very stringent: Everyone must be told of their diagnosis!" Thorny ethical tensions are common when we care for people from other societies. It's for this reason that on October 14th INMED is hosting the 2011 INMED Cross-Cultural Healthcare Symposium. How would you respond to Luping's health information disclosure crisis? And how would you do so in a way that is also culturally sensitive? Two ethical orientations are especially relevant:
In such ethical and cultural dilemmas contextualization is a useful guideline, calling for consideration of all points of view and negotiating the best possible agreement. Contextualization starts by asking all the interested parties - in this case the patient, the son and the doctor - to express their views. A conversation with Luping herself about what sort of information she does or does not want to know may help to resolve the standoff. I invite you to join me at the 2011 INMED Cross-Cultural Healthcare Symposium where we will enhance our ability to care for the immigrants, refugees, and foreign nationals in our midst. |
| LEARN NOTHING ABOUT GLOBAL HEALTH! |
"My boy, Tomas, is urinating pure blood!" Her speech was pressured and rapid fire. "He's been hemorrhaging for days. Is my boy going to die? " The anxious mother lifted her son, moving the pool of accumulating blood from the floor to her lap. The young, listless, glassy eyes of Tomas met mine, and I realized we hadn't much time to act.
"His bleeding is likely from a urinary tract infection and he needs an antibiotic - right? " I asked myself. That's what I'd learned in medical school at the University of Missouri. But this was Africa and the Kalukembe Hospital. I ran in pursuit of my mentor, Dr. Andreas Rohner. On hearing my diagnosis, he shook his head and rolled his eyes ever so slightly. Turning to the marshland, Rohner asked me guiding questions: Rohner: "Where do the children play?" Comninellis: "In those swamps" Rohner: "And what creatures live in those shallow waters?" Comninellis: "Mosquito larvae, a few fish, lots of snails" Rohner: "And what's living within those snails?" A light clicked on in my brain. "Schistosomas! " I exclaimed. "Tomas suffers from schistosomiasis of his urinary tract!" Rohner glowed. "Exactly, young doctor!" I trotted back toward the mother and her bleeding son, beating myself, "I'd studied schistosomiasis in tropical medicine school at Walter Reed. But when I first encountered someone with the disease I didn't even think of the diagnosis! Did I really learn NOTHING about global health?" Tomas looked forlorn; his mother, fearful. I quickly collected a urine sample and rushed to the lab. Sure enough, under a microscope I found schistosome eggs, confirming the diagnosis of this disease transmitted when the parasites that live in snails penetrate the skin of people in the water. Back in the clinic, I dosed Tomas with an antiparasitic medication and hastily arranged for a transfusion. Shortly, as the life-saving blood was dripping into the boy's fragile veins, I reconsidered my global health training experience. "Isn't the experience of caring for someone with a disease far more valuable than attending a lecture about it? Isn't supervised learning like I'm enjoying here with Dr. Rohner way better than any classroom exercises? " The vision for superior global health learning began to grow within me. I observed Tomas. The color in his face was returning and he began smiling at his mother, whose wrinkles were relaxing and voice filling with ease. This approach to education and care would prove to be life giving for Tomas, and later become the foundation of INMED's Certificate and Diploma programs. |
| WHAT PEOPLE GROUP IS MOST DISTRESSED? |
In our era of natural disasters, social unrest, and economic turmoil, this question is more than academic. We want our personal lives and our organized efforts to be significant, even virtuous. A first step is to identify with whom to invest our good will, and so the question: What people group is most distressed?
A people group, or ethnic group, is a cluster of individuals whose members identify with each other through a common heritage, language, culture, and/or ideology. Why address people groups and not simply nations? For one, nations contain a broad mix of both advantaged people and disadvantaged ones. Effectively addressing the plight of the latter requires an understanding of their particular culture. Who is taking advantage of this insight on behalf the world's most poor? Let me introduce you to Doug Blackall. A former professor of pathology at the University of Arkansas for Medical Sciences, I met Doug when he participated in an INMED International Medicine Intensive Course - one that's now offered each spring, summer, and fall. Doug explained following that training experience, "Because I now better understood the diseases of poverty, my naturally hard heart softened a bit, and I was in a much better place to effectively serve those in need." Shortly thereafter, Doug and his family moved to the United Arab Emirates, where he today serves at Oasis Hospital. The UAE is known outwardly as a relatively wealthy nation. But like all well-to-do countries, including China from where I'm writing now, the UAE also hosts many foreign workers and people groups of lesser economic status like Iranians, Palestinians, and Jordanians. Such people receive quality care from Doug and his colleagues. What people group is most distressed? Many are in peril: the Berbers of northern Africa, Kurdish of western Asia, and Miskito of Central America. Observing the lifestyle of Doug Blackall, we may do better to ask ourselves, "What will I do on behalf of people in distress?" and "How can I equip myself for this challenge?" How would you respond to such questions? I invite you to correspond with me on this subject. Please contact me via email or via Facebook. |