[Cecile Dinh, MD, MPH]

Hi Rebecca, what a wonderful story about your attending showing compassion and kindness to a homeless person. We all could use a little kindness these days and a second chance to get our lives back on track. Thank you for sharing.

[Cecile Dinh, MD, MPH]

1. I think expansion of faculty development programming in LMIC is difficult. As Dr. Burdick points out, there are likely cultural differences between those who lead the programs and those who are learning about faculty development. Unless the leaders are on the ground and understand the nuances of the low and middle income settings, it may not be effective in the long run. Furthermore, I have noticed that a lot of learners, once they have reached the level of leader, often times leave the low and middle income settings in search of better paying jobs, such that there is always a net loss of effective faculty and leaders in areas where they are needed the most.

2. I think all of the habits of exemplary clinical teaching noted in the article (Think Out Loud, Activate the Learner, Listen Smart, Keep it Simple, Wear Gloves, Adapt Enthusiastically, Link Learning to Caring, and Kindle Kindness) is translatable to education in LMIC settings. These qualities are always acceptable when trying to teach effectively anywhere. The one habit I would most support is to Adapt Enthusiastically. This habit allows the teacher to be flexible enough to alter a teaching plan in a way that will engage a large variety of audiences and learners. Enthusiasm is rarely regarded negatively, and I think learners are more excited to engage if the teacher expresses excitement for the teaching topic. I have had to adapt teaching plans at the last minute while working in both Tanzania and Zambia, due to lack of physical teaching space, things never starting on time, and not knowing what my audience’s baseline was on the topics. However, I found that on the days I was more irritable, my audience lacked attention to what I had to say. On the days where I was able to alter my previous plans, they seemed more engaged in the learning experience, which ended up being a better experience for me as well.

[Cecile Dinh, MD, MPH]

Hi Judy, yes, I definitely agree with you that CHWs should be compensated fairly based on the depth of their work. Without CHWs, it would be difficult to understand what a community’s needs are. I also like that you mentioned communication. It should not be a directive from the top down, rather, the information should be able to flow both ways in order to achieve good health outcomes.

[Cecile Dinh, MD, MPH]

Question 1: What additional elements would be necessary for universal health coverage to be effective?
Universal health coverage cannot be achieved if there are not enough doctors, particularly primary care providers. Using the US as an example, the grueling time and energy and money it takes to get through medical school is a deterrent for many people, thus decreasing the pool of possible physicians. There are government programs that can pay back some school loans as long as you agree to work in areas of high need, but overall, the path to becoming a doctor is not attractive. Furthermore, our country places high value on the so-called “curative” doctors – specialists and consultants who deal with a particular body system. A person with uncontrolled diabetes may need to separately see an endocrinologist, a nephrologist, a cardiologist, and a wound care specialist to treat all of his/her complications from diabetes. A PCP can hopefully work with the patient before the diabetes gets to be uncontrolled and prevent the need for so many specialists. No wonder our healthcare system is so fragmented and difficult to implement universal health coverage when there is not enough doctors overall and not enough emphasis on prevention of disease progression.

Question 2: How could low-resource communities better make use of community health workers?
I’ll get on my prevention soapbox again. CHWs not only can help with disease management, but they also can promote simple behavioral practices that have the ability to decrease the incidence of serious illnesses that contribute to a large resource burden (e.g. handing out soap to encourage washing hands and preventing GI illness) and be a well-recognized leader in the community. I have worked with some amazing CHWs whom the community really look up to and trust. This allows the flow of information to feed back to the health organization to determine what the most important community needs are and have a focused plan to address those needs.

[Cecile Dinh, MD, MPH]

Hi Julie – thank you for being honest about your experiences and what you gained after reading the article about cross-cultural competencies. I must admit, I myself sometimes find difficulty in culturally connecting with some of my patients. I am Vietnamese-American, born and raised in the US, but with a strong Vietnamese core. I speak Vietnamese, but sometimes, I find it difficult to connect with the rare Vietnamese patient I get on my schedule. Other times, I don’t quite understand my white American patients’ behaviors. I think there are different variations of cross-cultural barriers, but as long as you have an open mind, the interactions will go much smoother.

[Cecile Dinh, MD, MPH]

Question 1: What actions can healthcare providers take to decrease cross-cultural barriers?
Besides training on cross-culture interactions, there are many other things healthcare providers can do to overcome cross-cultural barriers. Language is important to communicate, so having interpreters for major languages of that area, whether through telephone or video is important. Our clinic and hospital system uses a video program called CulturaLink where we can connect fairly immediately to a live interpreter. This has helped our Spanish-speaking and Tagalog-speaking populations immensely, as well as many other less major languages in our county. Having a diverse staff can also help decrease these barriers; if patients see that there is a staff member at the clinic that looks and talks and understands them, whether it be the medical assistant, secretary, nurse, etc., they would be more likely to feel at ease and come back for health care.

Question 2: What prevention interventions could best help reduce consequences of complex humanitarian emergencies?
Many complex humanitarian emergencies are related to natural disasters and are not avoidable. However, the recovery time could be reduced with certain interventions, most related to prevention of infectious causes. Some interventions include strengthening WASH programs and having back-up sources of clean water should a more reliable source become unavailable. Another intervention could be boosting childhood vaccination rates so that infectious diseases it protects against does not run rampant when immune systems are already taxed during complex emergencies. Finally, having a strong disaster mitigation plan at the individual, local, and nationwide levels should theoretically help reduce the consequences of complex emergencies.

[Cecile Dinh, MD, MPH]

Hi Jacob – your example of providing a cow to each family for them to increase productivity reminds me a lot my friends’ work in microfinance. I am no expert on microfinance, but the gist is that unemployed or low-income people are given small loans to start their business and build on it. These loans then allow them to increase their business and revenue and pay back the loans at a reasonable rate. I’ve always thought this was a great idea, but always had some questions about it. Similar to the cows – how do you pick which individual or families to give a cow/loan to? What is the effect if the cow dies or the loan doesn’t pan out? I would love a mini microfinance lesson if anyone knows more about it!

[Cecile Dinh, MD, MPH]

Question 1: What actions are most important to improve global nutrition?
Food security is important. In this day and age where economies thrive on international commerce and imports/exports, I believe that is is important to keep food crops local (feed the nation first before feeding the world). Programs such as USAID help with agriculture in poorer parts of the world, and sustainability is key – allowing for the local population to learn and apply knowledge to improve and sustain their own country’s nutrition down the road when there is no aid available is important.

Question 2: In your opinion, what are today’s greatest obstacles to progress in global health?
The last few decades have seen an improvement in life expectancy and decreases in many communicable diseases around the world. However, areas that are in the middle of wars or have recently endured through a war, still struggle. Thus, political conflict obviously remains an obstacle to global health progress. Infrastructure in these areas to provide sanitation and hygiene, adequate and appropriate maternal care, and reliable nutrition, likely are lacking. However, struggles remain even when there is good infrastructure. Chronic diseases such as diabetes and heart disease are leading causes of death in wealthier nations. I had a patient whose diabetes was starting to get out of hand. He was reluctant to make any behavioral changes, and I recall him saying to me, “Well, if it gets any worse, you’ll just have another medication for me to take care of it, right?” This is the sentiment of many people I’ve met whose health is marred by chronic illnesses, and I have come to realize that enabling people to make better dietary and physical activity changes for their health is another big obstacle.

[Cecile Dinh, MD, MPH]

Hi Nelson – I completely agree with your point that maternal healthcare starts from birth! Children soak in so much more information and if preventative topics can be discussed with them from an early age as well as repeated as they grow older and with subsequent annual doctor’s visits or ad campaigns, they would be more likely to remember it when the time arises. Furthermore, as it states in one of the articles, women are more likely to send a larger portion of their earnings back to their family. In the same manner, I believe that women would be more likely to pass down the knowledge about women’s health that is embedded in them from childhood to their daughters and future generations.

[Cecile Dinh, MD, MPH]

Question 1: What is the mechanism, in your opinion, through which WASH and promotion of nutrition complement one another?
WASH and nutrition promotion are inter-related, as so many of the world’s illnesses start with and are exacerbated by poor nutrition, some of which can be prevented by WASH efforts. WASH can prevent diarrheal and enteric diseases; this leads to an individual not being ill so often and being able to better absorb nutrients needed for growing healthy. WASH efforts help keep stool (and the parasites that come with it) where they belong. As we all have learned, certain organisms found in mammalian fecal matter contain organisms that essentially become parasites in the human GI system, which can then further lead to malnutrition. On the other hand, by promoting nutrition, people then become aware of safe handling of healthy foods to eat and how to avoid getting sick, and perhaps will seek out WASH initiatives to install in their community.

Question 2: In your opinion, how should maternal healthcare be best expanded to protect women throughout their lives?
Maternal healthcare should be encompassed under Women’s Health, and it starts in female childhood. If a female child is able to grow healthy by getting vaccines and regularly checked up by a healthcare provider who can offer tips from a young age, I believe that this can empower them as they grow into adult women. They would be more recognizant of STIs, perhaps be able to delay becoming pregnant until they are financially and emotionally ready, and NCDs like cervical or breast cancer may be able to be detected earlier, leading to earlier treatment options.

[Cecile Dinh, MD, MPH]

Hi Judy, I completely agree with you! Community Health Workers are amazing! Where some people may have suspicious attitudes towards those in white coats, CHWs can really get on the level of those in the community and provide valuable feedback about the overall health of the community. I sometimes wish I could have that trust certain patients give our nurses and social workers, because then, I may be able to provide better care.

[Cecile Dinh, MD, MPH]

Question #1: From your perspective, what are the largest remaining barriers against worldwide HIV control?
This week, we learned about how HIV is transmitted, the natural course of the virus in human bodies, and treatment options. Much of the reason why HIV is still rampant is likely due to a combination of these learning points: difficulty changing behaviors, the asymptomatic window period, poor availability of ARVs in certain parts of the world, etc. Yes, I do believe that lack of widespread education and promotion is a barrier, but I wish also that more funding could be targeted to development of a vaccine. A vaccine (preferably administered in childhood) could help decrease the incidence of HIV in adulthood, and down the line, may help decrease MTCT as well, thus working towards elimination of HIV itself.

Question #2: Why, in your judgment, is pediatric HIV control lagging behind that of adults and what should be undertaken to reverse this status?
I think monitoring and surveillance of HIV-infected children are difficult. As in the article and lectures, many HIV+ mothers are lost to follow-up, and with that comes lost to follow-up of the child. Furthermore, children can be afflicted with many more acute issues such as other infectious diseases/NTDs, hunger, loss of parents or support system, that make it difficult to identify those who are HIV-infected. It is difficult to say what can be done to reverse this status. Perhaps more surveillance and dedicating CHW to follow-up as with the program in Thailand, or providing better antenatal care worldwide so that adequate therapy can be offered to pregnant mothers who are HIV+ around the time of delivery.

[Cecile Dinh, MD, MPH]

Hi Judy, I find it really interesting that you would see TB outbreaks on the Indian Reservation. Which one, may I ask? I only spent a month on the Navajo Nation in Shiprock, New Mexico, but I did get to spend time with a community health worker one day. It was one of the most eye-opening experiences – imagine riding in a 4WD car for 2-3 hours in the middle of a desert to get to an 80-year-old woman’s home that did not have electricity nor running water. If that individual were to become infected with TB by someone who had come to check in on her, I can only imagine the difficulty of directly observed treatment therapy for her. Or, treatment for any other illness or trauma she may obtain for that matter.

[Cecile Dinh, MD, MPH]

1. The high incidence and prevalence of TB in impoverished regions are due to a multitude of factors. Poor nutrition makes it difficult for the body to effectively fight the disease. In regions with low socioeconomic status, you also see a lot of people crowded into a small area (think housing inequality in urban China, slums of South Africa or India). Social crowding makes TB more easily transmitted from person to person. In addition, having a low income makes it difficult buy medications for treatment (though I believe some governments do subsidize the meds). All of these factors compounded together make it difficult to prevent TB from any one angle. As with a lot of things, the focus may need to be toward balancing socioeconomic equity for all.

2. Two interventions that would be most effective against NTDs are: a) training the local population to disperse into their communities and identify, treat, and survey NTD cases; and b) funding preventative therapy rather than treatment therapy. I think using the locals creates a grassroots effort that makes the population more aware of the disease and be able to obtain information on how to prevent or treat it in the future. A lot of education comes from word of mouth and by spreading information through word of mouth, I think people would be more trusting. Additionally, from a public health perspective, prevention is so much more cost effective than treatment. If funding can be used for prevention (i.e. vaccines, bednets, behavioral changes), people can lead overall healthier lives.

[Cecile Dinh, MD, MPH]

Gannen – I definitely agree with you that governance is a barrier to food security. The US is an example of that. We are one of the richest countries in the world, yet children in our country are still going hungry (and not eating the most nutritious food). Without getting too political, if we can divert some of our funding away from the jail system and put it into education and healthy lifestyle programs, I believe that our country can improve nutrition broadly from a young age. A country’s priorities can definitely affect food security.

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