Forum Replies Created
-
Posts
-
I agree with Matt on the second question. Specifically, good teaching “allowing the learner to engage in hands-on activities, adapting to new situations quickly”. Good teaching allows a safe environment for trainees to learn adaptation. There is no substitution for experience, and experience is only obtained in 1 of 2 ways, either in a safe supportive environment or without oversight, which may lead to patient morbidity and mortality. We strive to create this safer environment, but that is only possible with good teachers.
Question #1: Dr. Burdick describes qualities of effective programming and global collaboration. What barriers exist to expansion of faculty development programming in LMIC (low and middle income) settings?
I don’t know what the largest barriers would be, but I could surmise a few that are likely prominent. They note that it’s ideal for a new program to begin face to face. In the current COVID climate, that is logistically difficult. Meeting in country, though beneficial, is also expensive. They note that community engagement is critical, and along with that I could expect that community buy-in would would also be crucial for sustainability of a program like this.
Question #2: Which habit of exemplary clinical teaching is translatable to education in LMIC (low and middle income) settings? Can you provide an example of effective implementation from your own experience?
I believe many of the habits of exemplary clinical teaching are translatable to LMICs, and moreover, should be a focus in these countries. While LMICs may lack certain electronic resources for their learners, and may even lack text resources, bedside teaching is “free”. The same concepts, such as encouraging learners to develop independent plans, thinking out loud, and valuing the individual patient are not necessarily obstructed in low-income countries. That said, there will still be barriers. Staffing needs may restrict the amount of time that learners spend with senior providers, and some providers may have minimal precepted training altogether. I don’t have the experience internationally at this point to provide specific examples.
I agree with everyone that its astounding to see the information regarding time spent with patients and effectiveness of care in some of these countries. Without being on the ground and seeing this firsthand, its difficult to imagine spending <5 minutes with any patient, and this isn’t something that I’ve ever seen firsthand in the US outside of subspecialty medicine (where sometimes effective care can be done very quickly). I’d have to wonder if this represents cultural and institutional issues that are affecting their medical system that really need to be fixed at the source. “Trained” providers may also vary widely based on the quality of our training. In the US, we have a minimum 7 years of dedicated medical training to practice independently, but this isn’t the case in most of the world, so I imagine the standards are quite different.
Question 1: What additional elements would be necessary for universal health coverage to be effective?
Motivation of patients to improve their own health. In my opinion, it’s a serious misconception to think that making “healthcare” available to people is going to have a significant effect on their overall health. Sure, on a community level, we will see some improvement with increased vaccinations (although these are generally free for kids anyways with VFC, SCHIP), and universal healthcare will make a huge financial and health difference to those who are already suffering from serious chronic disease or those bankrupted by acute illness. That said, anyone who works in a community where a large percentage of their patient base is Medicaid (under which the healthcare is essentially free to the patient) will probably agree that this doesn’t result in better outcomes compared to patients with private insurance. Some of this will be due to the vast number of other socioeconomic factors that affect these patients, but some is due to a lack of investment in their own health. All things being equal (or even if nothing is equal), my patient who is self-motivated to improve will be the one that improves.
Question 2: What is the most appropriate role for community health workers in your particular community of interest?
I do not know the answer to this question. The country I will be working in soon (Liberia), has a developing health system and has been working to train residents in primary care. I would hope that the residents would become local leaders in training and developing community health systems, which utilize CHWs. The Ebola crisis a few years ago was economically devastating to the country, and while medically, there may not have been a lot the community workers could do initially, they may have benefited from community education that could be provided by CHWs, as much damage was done by people uneducated as to the means of spread of ebola, worsening the outbreak. Now that there is a vaccine, I can see CHWs being frontline in the administration of a ring-vaccination program, like that which was used to successfully contain the spread before.
I would agree with Nancy that while most disasters aren’t necessarily preventable, there is a chance for mitigation given appropriate preparation for predictable disasters. The types of disasters caused by war aren’t necessarily predictable or prone to mitigation, but those caused by other disasters are. Disasters that countries face from time to time, such as earthquakes, tsunamis, etc, can be prepared for to allow quick responsive action in the immediate aftermath.
Question 1: What prevention interventions could best help reduce consequences of complex humanitarian emergencies?
The most obvious answer to this from the article is vaccination. Outbreaks are one of the major complications of complex emergencies, and also one of the most preventable. While infrastructure of health systems, food delivery, housing, etc may be compromised in a disaster, vaccine mediated immunity will generally persist. High penetration of vaccinations is required, however, as weakened immune systems and living in close proximity may increase the R0 of the disease and increase the risk of outbreak nonetheless. Having in-country resources for ensuring a clean water supply (and WASH interventions) may also help prevent outbreak in these circumstances.
Question 2: Why, in your opinion, is disaster prevention minimized in comparison with disaster response?
Frankly, disaster prevention is boring. It’s not interesting, it doesn’t evoke images of struggling children, and you have to have an imagination to see the fruits of your work. We as humans have a very short attention span on average, and the majority of people who would give money or resources as a knee jerk to a natural disaster or complex emergency, they would not similarly give to a project to reduce risk in another country half a world away that they have no connection to.
In response to Matthew’s first point, I would say that a hospital or medical system knowing what interpreters they should have is given fact, however, it appears I would be wrong. It’s interesting to see how the medical system could do blindly miss the needs of that community.
That said, I’ve rarely used in person interpreters. These days, we like to talk into phones or stare at flat screen tablets with an interpreter on the other end of a shaky connection. These have all been hit or miss for me. I would love to have a real person to help interact with these patients, but I think that’s too expensive of a proposition in the current climate.
Question 1: What actions can healthcare providers take to decrease cross-cultural barriers?
This is a difficult issue to solve, as it’s not entirely solvable from one side. From the practitioners perspective, cultural competency training can be attempted, but in my experience these trainings are vague and do little more than to raise awareness of the issues at hand. Awareness can be helpful, but only if it pushes us to look for further real training. Real training has to occur in a way that is specific for each culture represented, and must be done either by someone from that culture or someone with significant experience for the way that culture’s customs and beliefs affect their healthcare. In my practice, that would require we have training from members of the local hispanic as well as haitian-creole populations. In my former setting, we would have needed to find members of the nepalese community. It has been abundantly clear to me in practice that there are barriers to care within these communities compared to other communities, but I can’t always tell what those barriers are, and how to address them.
From the other side, the patient perspective, we are limited in what we can do. Some of these barriers are going to involve aspects of culture that are impractical to address from the practitioner side in our current environment. Our current models of funding and scheduling in primary care would make it difficult to travel into the Nepalese community to do a series of home visits, and appropriate interpreters would be required (my experiences in use of tele-interpretation with the Nepalese community has been less than ideal, possibly due to different dialects used). Our current model of bringing patients into the office is the most financially viable, but not necessarily conducive to care in some of these communities with limited transportation, poor medical literacy, and high burden of chronic disease. Having practitioners that live and work within these specific communities would be infinitely more beneficial in building therapeutic relationships, unfortunately, at this time my current experience is only in academic medical centers where we are distanced in one way or another from the community that we serve.
Question 2: Describe how short-term healthcare trips can become more effective.
There are a number of important factors that can help us to be more effective with our international trips. The most important of these includes having focused goals and ensuring we aren’t doing harm.
When considerations are made for an overseas medical trip, the goal cannot simply be to provide medical care. Effective medical care can only occur in the context of an existing system (except in specific circumstances such as disaster response). Reasonable goals could be to temporarily support a local medical team that will continue care after you leave, to relieve overworked providers at a hospital, or even somewhat self serving goals, such as experiencing and learning from the local culture, or learning aspects of medicine in this environment.
Whatever your goal, however, it must be accomplished in a way that avoids harm. There are numerous ways that a medical provider can create harm when working overseas. It’s not as simple as giving good medical care. On a small scale, a medical trip that provides care where it isn’t needed could have financial implications for the local provider, as short term mission care is often free. Alternatively, providing care without appropriate follow-ups could result in unintended medical consequences for patients. In the long term, the widespread availability of doctors or other providers willing to work for free may remove any urgency to develop a regions own medical care, or train their own providers. All of these aspects must be balanced when planning overseas medical trips.
All of that said, the best way to make trips more effective is likely to partner with providers and agencies already on the ground. These people will best know how to avoid the above pitfalls, and to make your team an asset while you’re there and not a hardship.
I’ll semi-disagree (but not really) with Matthew and state that I don’t think that the western diet itself is an issue. I believe it’s entirely possible to eat jelly within the western diet, and the poor health and nutrition we see is due to specific dietary choices that we make, such as unhealthy snacking between meals, overuse of sweetened beverages, etc.
Responding to Matthew’s answer regarding neonatal resuscitation
IMO, I think the focus shouldn’t be in deepening the education of these providers, but rather ensuring a rather light minimal education in neonatal resuscitation. I could teach someone to do quality CPR in about a minute; its a very simple skill that saves lives. Neonatal resuscitation is similar in that the majority of what makes a difference (tac stim and PPV) can be taught in a very short period of time. While the studies referenced showed some waning of skills with time, I wonder what the practical effect of this was, and did it result in worsening outcomes over time? I also wonder if the finding of waning skills is actually due to provider memory, or reluctance to adapt to new methods of practice, given that the article notes persistence of suctioning even immediately after training.
Question 1: What actions are most important to improve global nutrition?
I’m not sure that nutrition is an issue that can be tackled at a global level. Every region has both different potential for farming as well as different traditional foods, both from plant and animal based sources. Countries that have large vegetarian populations (India) require different protein sources from those that eat meat. Micro and macronutrients present in the traditional diet will drastically vary by location. In urban areas, fortifying basic food sources may be sufficient to fix micronutrient issues, in rural areas where farming may be subsistence or foods may be limited, different strategies are likely required. I think we can agree that the vast majority of processed foods are not beneficial to humans at large, however, I don’t view this as the issue, as cheap processed foods may be a reflection of poverty and not an indication of societal norms. I expect the most important action to improve global nutrition is for each country to evaluate its own deficiencies, its own strengths, its own resources, and the availability of outside resources (imported food sources) and develop a plan that incorporates these to make nutritious food available to their population.
Question 2: In your opinion, what are today’s greatest obstacles to progress in global health?
I think the single greatest current obstacle to progress in global health is economic stability. COVID has led to economic recession in basically every country, and with that comes lower individual income, delayed educational opportunities, difficulty in accessing healthcare (or overwhelmed systems), possible disruptions in sanitation, and decreased preventative care. If we forget about the current climate, we can see that this same set of circumstances could occur with localized disease (such as with ebola outbreaks in the congo or liberia), or from other factors that damage the economy (war, political unrest, or just poor governmental management). Without economic stability, we have no way to build the systems required to provide this progress on a local scale, or we may see our progress disappear overnight.
Question 1: What actions should be taken, in your view, to increase availability of basic newborn resuscitation in low-resource communities?
This article makes clear that this is a complicated issue with no one-size-fits-all solution. The range of settings in which newborn care is delivered, and the range of attending providers (if present), makes it difficult to focus on training a set of providers to administer the optimal care. What we do know is that moms and babies benefit from having a skilled provider present at birth. We also know that the vast majority of live births can be resuscitated without advanced equipment or interventions. I believe there are two interventions that would have the greatest impact on newborn survival, which are:
- Having a skilled birth attendant present at all births. This could be accomplished by ensuring there are enough providers to be present at home births OR by ensuring that the majority of births are done at a birthing (or other medical) center. The second of these will allow for consolidation of resources and manpower, and would be preferred if possible.
- Ensuring that birth attendants are trained in at least the minimal resuscitation steps. Again, we know that the vast majority of births do not require significant interventions for resuscitation, so focusing on fundamentals (drying, warmth, stimulation, and bag-mask ventilation) will have the greatest impact on neonatal mortality.
Question 2: What is the mechanism, in your opinion, through which WASH and promotion of nutrition complement one another?
WASH mechanisms should reduce the populations risk of infectious disease, specifically parasitic disease, which can be a strong contributor to malnutrition. Nutritional supplementation and sanitation are both aspects of overall nutritional health, which in turn affects growth and mental development as noted in the article.
I agree with Judithe that community health workers are probably the key to tackling non-obstetric related diseases, but I think this is also something that has to be treated very carefully. The focused scope and training of these workers not only allows them to treat well the diseases that they know, but also recognizes that certain conditions have a greater impact of morbidity and mortality within the community, and can allow governments to focus on diseases that gives the greatest societal impact. As an american practitioner, I can see my focus at many office visits being pulled in directions that won’t necessarily lead to health benefits for the patient or community, and I could forsee a community healthcare worker having their focus pulled away from the diseases of greatest impact to treat diseases that may not have a similar impact. Additionally, treatment of chronic illness has more extensive long-term costs, higher diagnostic requirements, and often requires much more extensive training for the provider. This shift to treating NCDs must come from a top down approach with the requisite funding and support to ensure that it has a positive impact.
Question 1: What do you believe are the most direct impacts of conflict upon the health of pregnant women?
*
While this article shows that conflict can in some cases lead to easier access to care, I expect that overall, conflicts will result in worsening health of pregnant women. Under normal circumstances, pregnant patients are a vulnerable population and at risk for adverse health events. They have increased health monitoring needs (ie, seeing prenatal providers), increased caloric needs, increased needs for assistance with regular activities as pregnancy progresses, and increased risk of severe complications of the prenatal period, delivery, and postpartum. Conflict may serve to magnify many of these vulnerabilities. Although this study did potentially show that women living in camps may have more access to skilled attendants, women NOT living in camps are likely to be faced with more difficulty accessing medical care, accessing necessary medications, and accessing appropriate nutrition, all due to the destruction of infrastructure in their country. Additionally, for those living in camps, there is an increased risk of violence against women in general, including the pregnant population.
*
Question 2: In your opinion, how should maternal healthcare be best expanded to protect women throughout their lives?
*
That isn’t really the question we should be asking. We don’t need to just expand maternal healthcare, but convert to a system of care that encompasses women’s health issues and the NCDs that they face now that mortality related to childbirth is dropping. It isn’t difficult to identify which health problems come to the forefront as people live longer. This article lists some of these, but a quick look at health statistics in any country will fill in the gaps.
–
The hard question is “how do you fund this?”. As a vulnerable population, pregnant women and children have a special place in the hearts of donors worldwide, and it isn’t as hard to find funding sources directed towards their care. When you start discussing other NCDs, diseases of aging, cancers, and the like, you lose the pathos that stimulates action from the government, private donors, and NGOs. What you’re asking for here is development of a healthcare system, and not just piecemeal treatment of specific issues that affect segments of society. The monetary and logistical requirements increase dramatically, and so must buy-in from those who fund it.Responding to Nancy regarding pediatric HIV control. I think its great to think about creating comprehensive care for pregnant patients, but what does that really mean? When we think about what pregnancy care looks like in many countries, it might be one or two prenatal visits with a Hg check and iron supplementation, if they’re lucky. The availability of complex care, including what would be required to treat a neonate with HIV exposure may be a few degrees beyond what is available rurally in many areas. I think some of our goals may be unattainable in the short term until there is expansion of rural clinics and training of providers who can deliver the level of care that we need in those communities.