[Casey Kernan]

Taylor I agree with your response to question #2. An effective teacher must activate the learner. I love Kahoot and it definitely makes for a more engaging and meaningful lesson. It forces me to commit to an answer. I have experienced various precepting techniques and find that the faculty that activate my learning are my favorite. They give me a sense of autonomy and don’t tell me what to do. I think most learners respond best to this style. At first the so called “pimping” can be intimidating but if it is done in the right way with an emphasis on pushing me to think critically I feel motivated to learn.

[Casey Kernan]

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?
One obvious barrier to me is the current COVID19 pandemic and it’s disruption locally and internationally. This article focuses on the importance of avoiding persistent dependency and gaining trust. While zoom, Skype and other webcam based services have allowed us to connect to others I really think a true face to face meeting can foster more trust and understanding. COVID19 has limited educators travel to countries to form these relationships and obtain personal stories. Efforts and resources once focused on global education may now be shifted more towards COVID19 relief efforts. Regions facing COVID19 and conflict may not see the immediate importance of global education and resort to more of a survivalist mentality. Adequately trained personnel is another barrier as we seek to expand global collaboration.

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?
I appreciate all of these habits and believe they are all translatable to education in LMIC settings. With the advent of the electronic medical records system and our reliance on diagnostic tests and imaging, we as clinicians are pushed from the bedside to the computer more. We are focused on production based, performance medicine which cuts our time with patients. Given this, I really appreciate the “put on gloves” concept. As an osteopathic clinician, I was trained with the understanding that touch is not only diagnostic but comforting and can help make a patient feel that their physician truly cares. I find that this is often what patient’s want to. This skill translates into LMIC settings but we must be culturally sensitive when examining a patient. Effective teachers that utilize bedside rounds show that they care about this human connection of touch beyond it’s diagnostic purposes. Through residency, I’ve learned to be more comfortable with the unpredictable nature of medicine. I think effective clinical teachers exemplify that through adapting enthusiastically. This is hard for some as it does take some humility as the article discusses. From my experiences, when a teacher shows humility and some vulnerability it doesn’t make me question their knowledge or competence but allows me to trust them more. It also helps me as a learner realize that mistakes do happen and that plans can change. I find that when other residents are vulnerable and admit fault it allows everyone on a team to be more open, honest and to learn. Ultimately, I believe patients appreciate this transparency as well. This concept of adaptation is critical in LMIC settings when continuity is disrupted by conflict, natural disaster and other social reasons. Finally, as a medical student and now resident I find that the most effective teachers are ones that practice medicine with kindness and care. As many providers face burnout these simple but very important qualities can be lost. These qualities in LMIC settings allow teachers and learners to connect with patients and make everyone on the healthcare team (including patients) feel a sense of gratefulness and love.

[Casey Kernan]

Emma I agree that midwifery has benefits in the US and I too have witnessed their underserved underappreciation. In developing countries they could have the role of providing prenatal care and low risk home deliveries. This would certainly lower neonatal and maternal outcomes. They could expand access for woman to receive good prenatal care. High risk features of previous or current pregnancies could be identified and there would be more time for alternative delivery methods. Midwives with more experience could learn about managing pregnancy complications and help these woman receive postpartum care that include fistula repair, lactation support and mental health services. You are totally right about the communication piece which is so key in any pregnancy or delivery.

[Casey Kernan]

Question 1: What additional elements would be necessary for universal health coverage to be effective?
Universal health care by 2030 is an ambitious feat as the current state of health care in different communities and countries looks widely different. I agree with the article in making effectiveness, safety and patient centeredness a priority. We need policy, funding and research to identify populations that do not have access and find creative ways to provide it. Patient or people-centered care would allow one to detect disease and prevent disease through informing and encouraging healthy lifestyles and education. Services that provide cradle to grave care with equity, fairness, affordability and cultural sensitivity would require personal. This capacity of well trained staff, volunteers and community leaders could include nurses, midwives, behavioral health/mental health workers, chaplains, palliative care, ethics, public health, dietitians, pharmacists and rehabilitation specialists. Effectiveness would require leadership and the development of protocols and training to insure quality healthcare is administered. Transportation, medical records and communication systems for different levels of care could help facilitate safe transfers to higher levels of care. Focusing on essential health care services (prevention and treatment of communicable, non-communicable and chronic disease) as well as providing basic woman’s health care rights would help reduce health care costs and could be a start to any developing countries health care coverage, with goals to expand it as the countries political and economic status improved.

Question 2: What is the most appropriate role for community health workers in your particular community of interest?
Community health workers in my residency training have played many different roles. They improve the coordination of care and provide help to patients through social support, care management, housing, transportation, counseling, assessment and informal counseling. In global health, their appropriate role depends on their training and clinical experience. I see the role of community health workers in developing countries to be trained with the ability to provide basic primary care and really focusing on prevention through immunizations, the diagnosis/monitoring/management of chronic disease, women health and mental/behavioral health services. A community health worker could help coordinate care to those that may have barriers. They could provide palliative care and rehabilitation services. Their scope may be narrow or wide depending on their prior experience.

[Casey Kernan]

Alice I agree with your response to question #1. The assessment of need, risk and vulnerability within a community are very important. You have some great prevention intervention ideas but it really is up to the individual when it comes to some of these. In regard to your comment on COVID19 and reducing risk factors (obesity), these are interventions that require intrinsic self motivation and I think this is why prevention strategies can be so difficult. Many people continue to eat high density meals from Mcdonalds multiple times a week and they still smoke a pack of cigarettes despite the known negative health benefits. This concept reminded me that any prevention intervention should acknowledge the individual and communities motivation, desire and understanding.

[Casey Kernan]

Question 1: What prevention interventions could best help reduce consequences of complex humanitarian emergencies?
Unlike natural disasters which can’t always be predicted, most complex humanitarian emergencies develop over time. This allows some time to implement preventative measures. This could start with a needs assessment and an understanding of the vulnerabilities as described in the modules. It would look slightly different for each community. Most complex humanitarian emergencies affect vulnerable communities with low resiliency so interventions focused on vaccine education and administration campaigns, WASH and nutrition would reduce some consequences. This is difficult when communities are already fragile and now members are dispersed and displaced. Inevitably displaced families without access to safe shelter, water and nutrition will be at risk for contracting non-communicable diseases as well. Creative ways to make management of NCD accessible will be important. A team or organization dedicated to sexual and reproductive health is very important during a complex humanitarian emergency as sexual violence may increase and labor/birth rates can also increase. Preventive measures must be organized, strategic and well communicated to the public. Delivering the message is easier in well developed countries but would require more efforts in developing countries.

Question 2: Why, in your opinion, is disaster prevention minimized in comparison with disaster response?

I would agree that disaster prevention is minimized and does not get the same level of attention that the actual disaster and response benefits. Disaster prevention requires resources, money, skills and expertise. Many of the communities that would benefit from disaster prevention lack all of which. They are vulnerable and lack resiliency. When a natural disaster strikes, international response with media and publication draws attention and international aid ensues. In my opinion, the United States response to COVID19 demonstrates this. We have become more reactive and less proactive, especially under current administration. I think that it takes a disaster for people to sometimes realize the importance of disaster prevention so following a disaster the prevention piece may be valued and supported.

[Casey Kernan]

Abigail I agree that short term healthcare trips are more effective when there are consecutive short term trips and adequate continuity or follow-up. This is especially true for healthcare trips that involve the administration of medical supplies and medications. I had the opportunity to travel on a trip focused on improving public health infrastructure. It was a short trip and only a week long but it was an established program that had built years of lasting relationships with the community.

[Casey Kernan]

Question 1: What actions can healthcare providers take to decrease cross-cultural barriers?
Improving cultural competence can help health care providers decrease cross-cultural barriers for populations both in the US and abroad. The ability to communicate, understand and build trust with a culturally different population than one a person self identifies with seems to be foundational. This can be accomplished through exposure and immersing oneself with others that are coined “different” while learning their language, communication style, beliefs, attitudes, and behaviors. This often will feel uncomfortable at first because it requires learning something that is unfamiliar and might be contrary to one’s own beliefs. Understanding your own implicit bias is important as well. With this self awareness and new understanding of other’s culture we are able to build trust. Through trust, healthcare providers can care for people while integrating what is important to both parties.

Question 2: Describe how short-term healthcare trips came become more effective.
In order for short-term healthcare trips to be effective, they have to be strategic, sustainable and most importantly accepted within the receiving community. It is important that the community receiving the healthcare is surveyed and assessed through a respected individual among the community. Once there is a need identified it could be measured (number of infections per 100 people, # of people lacking water, # of EOS in newborns, etc). This allows the efforts to be measured once the short-term healthcare trip is finished and may identify when the trip or aid may again be needed. In the long term, it’s important to give the community the resources to provide similar efforts themselves. This could involve the election of community leaders and officials that can work with foreign aid or local departments to maintain the healthcare trip efforts or success. I do agree that short-term healthcare trips must be strategic and efforts that do not have the communities interest at heart can be harmful.

[Casey Kernan]

Autumn I appreciate that you point out the increased risk of substance use and need for mental health services in those that are living in poverty. I agree that the added stress of living in poverty can lead to increase in substance use and alcoholism. Those who suffer from co-occurring disorders (both psych and substance use) begin to use substances as a form of self medication. If they had access to quality mental health and primary care they would find healthier ways to manage their stress and psychiatric conditions. It is a hard cycle to break when poverty is involved as these people are less likely to have quality health insurance, access to care and stable housing.

[Casey Kernan]

Question 1: What actions are most important to improve global nutrition?
We must understand what end of the spectrum a country or community lies on as malnutrition can be caused by nutrient deficiencies in both underweight and overweight populations as stated in this article. Each community will need a strategy or plan that focuses not only on food but also the production, consumption and distribution of food. In countries with widespread poverty rates we must focus on proven nutrition strategies such as encouraging breastfeeding, fortifying food with necessary minerals and micro/macro nutrients and supplementation (i.e. vitamin A) to prevent the severity of disease. In these countries we must also consider clean water and commit to safe sanitation so that the food that is consumed does not cause disease itself. Countries in poverty and surrounded by conflict may not have the means to produce agriculture itself so we have to get creative by using the resources at hand and helping produce sustainable solutions (solar powered energy, self producing livestock, etc). In developed countries a focus on waste seems important and encouraging consumers to eat less meat and high density meals. Understanding where our food comes from and being mindful of the lower carbon footprint associated with eating and supporting local farms is equally important. The western diet is beginning to affect developing countries as we see higher rates of coronary artery disease, heart disease and stroke so must also focus on educating about chronic disease and what types of foods contribute to it.

Question 2: In your opinion, what are today’s greatest obstacles to progress in global health?
I believe that the biggest obstacle to progress in global health is income inequality. We see this worldwide. Those that are born in low income, poverty stricken families and communities have limited access to a number of social services that are meant to improve health. It’s quite obvious of the impact when we look at the life expectancy for stratified incomes. Those that make more money are healthier and live longer lives, often with less disability. This obstacle is difficult because we must change entire economies and societies around those in poverty. It feels as though children are born into a birth lottery that determines their future opportunity and health. Until we work towards reducing this giant income gap, children born into poor families will continue to face this self fulfilling prophecy as I see it. This global income inequality leads to large disparities in health, wealth and education.

[Casey Kernan]

Alice I like that you bring up nature vs nurture with your response to question #2. Childhood development and growth is certainly linked to parental involvement, love and stimulation. When a child scores low on their ASQ (developmental survey) we often give them an activities sheet in our clinic so that the parents can work on supporting their neurobehavioral development. A child that feels loved will see the world as more safe and secure and this can keep the child’s natural curiosity alive.

[Casey Kernan]

Question 1: What actions should be taken, in your view, to increase availability of basic newborn resuscitation in low-resource communities?
The review article demonstrated that many neonatal deaths could be avoided with simple resuscitation efforts such as stimulation and bag mask ventilation. These efforts are not carried out as well or as often, due to lack of skilled birth attendance at the time of delivery and the necessary equipment. The challenge lies in bringing these resuscitation efforts and equipment to families that deliver outside of hospitals and medical centers. It is easier to organize birth equipment and staff at a delivery within a hospital but the quality of resuscitation effort can still vary. Education once again seems to be key at preventing and reducing newborn mortality. Educating families, community members and skilled birthing attendants on birthing complications, newborn vitals and the sequence of resuscitation can help identify the importance of having simple equipment at the time of delivery and how to use it. Courses like NRP are great but I agree these training sessions need to be continued education as the information is lost quickly. As an intern, we take NRP courses and then again as a 3rd year and I can attest to the loss of knowledge as these are skills that we don’t use daily. Utilizing educational training with a device or cell phone and holding hands on “mock codes” or “clinical vignettes” quarterly (about 3-4x/year) would allow for these skills to be more fresh for those that frequently attend deliveries. Training a few community leaders that can attend births at home may also help. The use of birthing packages with antibiotics, sterile water, hand sanitizer, bag mask ventilation, clean towels and the various other instruments needed could allow the equipment to be more readily available. After watching the videos in the modules, nearly every skill starts with washing your hands. Many of these families don’t even have access to clean water. Understanding each communities barriers to care and essential needs is important. Fortunately only <1% of deliveries requires more intensive efforts so training members in a community and providing delivery packages that can be utilized in homes could help reduce newborn mortality significantly.

Health and Nutrition Interventions for Infant Development. Lancet 2018
Question 2: What is the mechanism, in your opinion, through which WASH and promotion of nutrition complement one another?
Water sanitation, hygiene and undernutrition are closely linked. Children who lack access to clean water and sanitation are at greater risk of becoming infected with diseases that lead to diarrhea, intestinal worm infections and malaria to name a few. These infections often lead to malnutrition as children with diarrhea are less likely to be able to absorb nutrients from food, no matter the amount of nutrition they are offered. Poor environmental hygiene can lead to standing water and fecal matter which can attract mosquitos and worms and propagate disease through necessary vectors. A focus on nutrition can improve immune function (advocating for breastfeeding up until the 1st year of life) which can help fight disease when it is acquired.

[Casey Kernan]

Nicole, I totally agree with you. We need to break down the inequality and give women economic opportunity. They deserve a voice and it saddens me that some live in fear to advocate for their families. I like your idea of the use of standardized protocols. Utilization in the US for treatment of postpartum hemorrhage, elevated blood pressure certainly reduces adverse outcomes. It could be utilized in people’s homes with oral medications or routes that may or may not require an IV depending on what available medical staff are there.

[Casey Kernan]

Question 1: What do you believe are the most direct impacts of conflict upon the health of pregnant women?
Conflict affects the health of pregnant women and their fetus/fetuses significantly as well as the entire family. It displaces resources for mothers and they are already struggling because they are treated unequally in many countries. They lack the social support to obtain an education. Preconception counseling, maternal health and postpartum care/mental health is not as easily accessible. Woman in conflict areas have higher fertility rates as cited in the reference provided. This could be a coping strategy, a way to replace loved ones they have lost or a result of increased vulnerability to sexual violence. Woman who become pregnant through sexual violence may be less likely to seek medical care due to feelings of shame and trauma. These women may have undiagnosed infections (HIV) which not only affects her health but her progeny as well. During conflict, pregnant women may act as the head of the household and the father figure may not be present. They may not feel safe to seek care as their communities’ infrastructure is destroyed and in shambles. The added stress of carrying a child in a high conflict zone leads to other negative health outcomes including poor sleep, poor nutrition, unsafe water and stress which can lead to preterm labor and delivery. Surprisingly, once in labor, access to surgical interventions appears to be better due to foreign aid but this aid could be temporary. During COVID19 global pandemic and other ongoing conflicts in the world, countries may restrict access to surgical interventions and trained/competent medical personal. These women are often forced to be displaced, flee and escape the conflict. They then are essentially lost to follow-up and may be forced to deliver while traveling, which ultimately puts their life and their children’s lives in danger. Pregnancy is stressful and difficult in a resource rich community setting but in war zone a pregnant mother and her child suffer significantly.

In your opinion, how should maternal healthcare be best expanded to protect women throughout their lives?
Maternal death is affected most commonly by hemorrhage and major bleeding, infection and pre-eclampsia. Good maternal care starts well before pregnancy and beyond. Women should be educated about puberty, sexual health, conception, family planning, the risk of acquiring STD’s/infections and how to identify, manage and prevent further disease. They should be provided with access to these services. They should be offered services to identify disease early (cervical, breast cancer). Women leaders need to hold positions of power to help advocate for their community’s health.
Mother and newborn health is linked. We must know mom’s pregnancy risk factors and sometimes these can be chronic conditions. Elevated blood pressure whether chronic hypertension or gestational hypertension should be identified and managed and delivery early, if uncontrolled. Blood pressure can lead to pre-eclampsia, eclampsia, seizures, stroke, uteroplacental insufficiency and fetal demise. Close monitoring and management of these conditions have effects on maternal health. Gestational diabetes is another non-communicable disease that needs to be addressed and managed early. Gestational diabetes can lead to macrosomia and infants that are large for their gestational age. These large newborns have higher risk of birth trauma, hypoglycemia, neonatal asphyxia and fetal loss. Mothers are faced with a postpartum risk of obesity and type 2 diabetes. Mental health is another concern and encompassing behavioral health and pharmacologic therapy in their care is crucial. While we continue to address inequalities that women are faced with, giving them a voice to let them tell us what they need and giving them the resources to improve the health of their communities is what I think will be most successful.

[Casey Kernan]

Nicole, I agree with both of your answers. You are totally right, the latency period of HIV symptoms can be quite long which gives the virus quite the advantage to propagate and infection others. I know here in the United States, the USPSTF recommends that clinicians screen for HIV infection in those aged 15-65 years old who are at increased risk and in all pregnant patients. If similar recommendations were universal in other countries and they had the means to accomplish it we may capture some of these asymptomatic carriers. The stigma definitely works against these efforts though. If people knew that it was standard to check/screen for HIV in certain settings, i.e. pregnancy perhaps we could avoid the avoidance of such screening.

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