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Brain drain has been going on for a very long time and is unlikely to stop until the economic situation in these countries improves and political stability improves. It seems to me that many rural and underserved areas in the US rely heavily on foreign medical graduate physicians that have to do a 3-year J1 visa waiver in an underserved area. Another incentive to get physicians to work in underserved areas is the Public Service Loan Forgiveness Program. I don’t know too much about this or how stringent the criteria for qualifying employers are.
I once had a housemate who was a PA student who was in a program that funded her studies, but in return she had to work for a limited number of federal employers afterwards for a couple of years (the Indian Health Service was one of them – a very medically underserved area).FAIMER Global Faculty Development- A Sustainable Partnership Model to Advance Health Professions Education. Academic Medicine, 2023
Question #1: What barriers exist to expansion of faculty development programming in LMIC (low and middle income) settings?Funding is a major concern and the only one directly mentioned in the article. For example, Brazil lost its FAIMER faculty development program due to a change in government and loss of funding. Another challenge is the need for adapting Western educational models to the local non-Western context.
Inconvenient Truths About Effective Clinical Teaching. Lancet 2007
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?All habits of exemplary clinical teaching discussed in this article are translatable in LMIC settings. These habits do not require technology; they require faculty development and more importantly an attitude of caring for the patient that is then modeled to learners.
I personally have learned from clinical teachers that showed empathy towards patients, that listened patiently, expressed their sorrow about a bad diagnosis, and constantly showed respect for patients and families, as well as learners. Learning from these role models is most effective, I think.Bernadette, I agree that political stability is foundational to any universal healthcare coverage. Infrastructure for the delivery of healthcare needs to be present as well. It’s been my observation that even in countries that have relative political stability, providing universal healthcare coverage is challenging, or it might be provided, but at a very low and not really meaningful level (this has been my observation on mission trips in Honduras and Nicaragua, and based on conversation with local doctors there about the challenges they face). For example, in Honduras, a country I will be going to for the third time in June for a short-term medical mission trip to serve victims of human trafficking (aka prostitutes), patients can see a doctor for free in the public health service, but the waiting times might be long for specialists (6 months), medications and tests have to be paid for out of pocket, and the training of the doctors might not be very good, leading to diagnostic errors.
Universal Health Coverage Evolution, Ongoing Trend, and Future Challenge- A Conceptual and Historical Policy Review. Frontiers Public Health, 2023
Question 1: What additional elements would be necessary for universal health coverage to be effective?
In my opinion and my reading of this article, there are 3 major requirements for achieving universal health coverage. The most important one is a workable and sustainable financing model for universal health coverage, since providing healthcare is expensive, and specialized treatment very expensive. Difficult decisions need to be made about resource allocation. While in theory it makes sense to invest more in disease prevention, if the consequence is that fewer resources are available for treatment of disease, the people suffering from disease will be very unhappy if they don’t receive treatment, including if they cannot get access to expensive treatments, like most cancer treatments these days. Countries that are able to improve their economy, including through the choices that are under their control, such as not allowing corruption, or making wise economic choices, can more easily implement universal health coverage.
The final crucial factor for effective universal health coverage is the need for sufficient well-trained healthcare personnel who can provide the needed care.Community Health Workers Bring Value and Deserve to be Valued Too- Key Considerations in Improving CHW Career Advancement Opportunities. Frontiers Public Health, 2023
Question 2: What actions could improve community health workers career prospects?
The career prospects and retention rates of community health workers could be improved by offering higher wages, better compensation and benefits, opportunities for training, advancement and promotion, providing mentorship and supervision, but also allowing CHWs to function in supervisory and project management roles, valuing lived experience over formal education, and improving the professional status of CHWs, perhaps through educating other healthcare professionals about the role they play.Haley, I totally agree that educators can encourage their learners to have a certain mindset. How would they exactly do that? Verbally telling them during a lecture/workshop, by example / role modeling?
I agree that the historical context of discrimination against minorities in the US in particular is very important. Coming from Germany and not having learned about some historical injustices in medicine like the Tuskegee Syphilis study, it was very eye-opening for me when I learned about it and similar examples of ethical misconduct (even crimes) against minority patients perpetrated by physicians or other healthcare workers and researchers. It helped me understand why my African American patients were so mistrustful of the medical team’s recommendations, especially around end-of-life issues.
I agree that what the article calls knowledge transfer, such as about the cultural norms of the minorities that live in your area of practice, does play a role, because often we are not even aware that other people might think or perceive things differently than we do.Regarding question 2, you mention the importance of preparation, i.e. having a plan, and training of the healthcare and other disaster management staff. I agree that in most disaster management contexts that is very important, and that is what the article mostly talks about. But I think the question was specifically about how to prevent the consequences of complex humanitarian emergencies resulting from war. I think that is much more difficult, and I was struggling how to answer the question. Typically, governmental authority breaks down in conflict zones, so the disaster plans that have been developed will likely not be implemented, and healthcare staff may be refugees themselves, or have lost the medical assets they need to do their job (hospitals, medications, etc).
Cultural Competence in Healthcare Leadership Education and Development. Societies, 2022
Question 1: What actions can healthcare educators take to help their learners to reduce cross-cultural barriers?
Healthcare educators can engage in both formal and informal education about cultural competency. Formal education appears to be most helpful if delivered in the context of voluntary, interactive workshops or other interactive delivery methods that allow free expression of ideas and questions, that are free of immediate disapproval or criticism, but rather a focus the positive skills already present in the learner and how these can be improved further. Informal education happens through role modeling and mentorship.
I find it noteworthy that the article mentions that cultural competence in healthcare is not something that can be trained into people, and that training interventions alone may not be very impactful. I think changing healthcare systems to make them more welcoming to people from different cultures is really important. Basic things like providing interpreters, maybe having patients respond to a questionnaire before the clinic visit about certain aspects of culture (e.g. are they comfortable with a male physician if they are women, or asking about cultural beliefs about health and disease, about whether they want diagnosis to be disclosed, who needs to be included in decision making, etc). Care needs to be taken not to allow discrimination by patients from let’s say patriarchal cultures against female healthcare professionals, or against ethnic minority physicians. Existing power differences in the US where women and minorities are disadvantaged need to be taken into account.Impact of Wars and Natural Disasters on Emerging and Re-Emerging Infectious Diseases. Frontiers Public Health, 2023
Question 2: What prevention interventions could best help reduce consequences of complex humanitarian emergencies resulting from wars?
From an individual patient and population health perspective, achieving near-universal vaccination rates for vaccine-preventable diseases could make a major impact. The recent polio outbreaks in Somalia and Syria and various yellow fever and cholera outbreaks could have been mitigated through adequate pre-catastrophe vaccination. BCG vaccination of children would also help reduce the disease burden of tuberculosis in children. Many diseases are not vaccine preventable, but ensuring vector control would be helpful.
Since most infectious diseases, whether vaccine-preventable or not such as malaria, are related to poor hygienic conditions and contaminated drinking water, ensuring adequate clean water, sanitation and hygiene before a disaster will also help reduce the consequences of complex humanitarian emergencies, though ensuring WASH during and after the conflict is also essential.I agree with Haley that promoting sustainable crops that don’t deplete the soil, e.g. by using crop rotation, and providing poor families with seeds is important. War and political instability are often the reasons why famines develop – see the current famine in Sudan that no one is talking about, and the situation in Gaza, that everyone is talking about.
Not every area of the world is suitable to agriculture. Where raising livestock rather than agriculture is the source of food and income for families, providing families with livestock is a good strategy – the milk from cows and the eggs from chicken provide needed protein sources.
Your insight that greed is at the root of so much evil in this world is correct. I’m sure you’ve heard of the concept of food deserts in inner cities in the US – areas where you can only buy fast food, unhealthy snacks, at stores like 7-11, but regular grocery stores don’t exist. With the recent increase in crime and retail theft in inner cities in many parts of America, I do see the other side as well – if I owned a business, I would not open it in a part of the city where chances of robbery and theft are high and go unpunished, as in many cities in California these days. Which just reminds us that these issues are incredibly complex, and there are no easy solutions. Of course the people that suffer both from food deserts and inner city crime the most are the poor and minorities. It’s interesting to read about what’s going on in certain Latin American countries – Ecuador which used to be considered safe now has become unsafe and unstable due to the activity of criminal gangs engaged in the drug trade. El Salvador, which used to be extremely unsafe, with lots of killings of regular citizens that didn’t allow their kids to be (forcefully) recruited in the gangs or refused to be blackmailed, and high levels of corruption and gang violence, now has become much for safe for the regular people, because the president Bukule has put most gang members in prison, and he just got reelected with somewhere beyond 80% of the vote, because he provided security to his country. There are concerns about unjust imprisonments of people caught up in the gang crackdown (e.g. because they used to be in a gang in the past and have a gang tattoo). It shows that people value security over freedom, if the state fails to provide basic law and order.Question 1: What actions are most important to improve global nutrition?
My conclusion from this article is that while there are promising micronutrients that may play a role in preventing or ameliorating certain diseases, the research and the science behind the micronutrients is not at the point yet that we can make any scientifically sound recommendations for supplementation with these micronutrients. Based on the history of research about vitamins, micronutrients, etc, there is reason for skepticism. Certain vitamins taken in excess can be harmful (vitamin E, for example). A lot of the nutrition research suffers from confounding, because it is based on self-reported historical food intake, which is prone to reporting bias. One also has to keep in mind that the supplement industry is a billion dollar industry.
Eating a balanced diet that contains a fair amount of fruits and vegetables is likely sufficient to provide us with the micronutrients we need.
My personal thoughts, independent from this article, about what actions are most important to improve global nutrition: Addressing the obesity pandemic in both resource rich and resource limited countries, and providing adequate and healthy nutrition (meaning foods that include protein sources, fruits and vegetables) to the poor are the most important actions.Question 2: In your opinion, what are today’s greatest obstacles to progress in global health?
Some of the most important obstacles include poverty and the associated lack of access to preventative care and treatment of disease; health system failures (example: lack of screening for syphilis in pregnant women, and failure to treat once identified); increasing rates of non-communicable diseases caused by unhealthy lifestyles and untreated chronic medical conditions such as hypertension, hyperlipidemia, and diabetes, due to lack of medications and lack of healthcare professionals.Julie, you make a great point about the importance of educating the husbands/men in the many very sexist and discriminatory societies in the world.
I think one way to tackle racism is by educating girls and women, and by passing laws that protect women, that ensure equality of the genders before the law, that penalize violence against women, that penalize honor killings, etc. There are interventions that governments can engage in that are effective. And fighting corruption is essential.Julie, I agree that promoting breastfeeding is crucial. Regarding your second point, could you give some examples of agricultural interventions how to diversify the diet or increase nutritional density? How costly would that be, and how feasible?
Question 1: Which, in your opinion, are the two most powerful pathways to improving infant growth in lower income communities?
It’s difficult to judge which interventions are most powerful. Promoting breastfeeding seems low cost and high impact. Making sure all pregnant women receive the required prenatal vitamins and receive adequate nutrition also seems easier to achieve than some other intervention, such as providing adequate mental health counseling and support, which requires trained providers and costs money. Providing free vitamins and nutritional counseling at the prenatal visits that pregnant women attend seem more impactful. In the Western world, of course, folic acid fortification of commonly eaten food (cereals) has led to a drastic reduction in neural tube deficiencies (not at nutritional outcome, but still very impactful). Vitamin D fortification of milk, another commonly consumed product, is another example of a society-level intervention that benefits many and does not require individual actions.
Regarding your response to Question 1:
I completely agree with you, Haley – the health of the mother is crucial to ensure the health of the baby.
Having a neonatologist friend who moved to Mongolia last year to work in a hospital in the second largest city there to improve the outcomes of newborn babies (Mongolia still has a very high infant mortality, even though it’s more a middle income country in many respects), I also see the importance of educating healthcare professionals in proper care of newborns with complications or premature babies in particular. That is what my friend is trying to do – help educate the doctors and nurses, teach them how to use easy low cost interventions (bubble CPAP), do simulation training with them, help them develop protocols for neonatal complications.