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Dr. Lee brings up a sad point about providers in lower income areas. They can’t make more than their patients can pay, so often they have less personal income, and can therefore not afford some of the upper tier educational products/services to stay at the top of their game. Sometimes this may include attending lectures at conferences which requires travel funds, etc. Or educational modules that are pay-to-play type. This then increases the healthcare disparity between lower and higher income communities as well.
1. I suspect that finding quality, willing participants is one barrier. Teaching takes a lot of time and effort, and being a good teacher takes even more. Finding people who are willing to put in that kind of effort continually, and are able to do it well, is difficult. Not to mention that working in lower- and middle-income areas is generally thought to be less glamorous. Overcoming that hurdle can be a challenge.
2. Perhaps I don’t understand the question, but I would have to say all of them. I don’t see why teaching methods in high-income settings would differ from low-income settings. People learn the same general way whether they are wealthy or not. The specifics may change because experiences are different, and previous experiences are useful in gaining new knowledge and understanding, but the overarching themes (thinking out loud, for example) would be beneficial for training in either setting.
1. Something highlighted in the article that needs to change is incentive structure. Providing providers of any educational background, be in physicians, nurses, etc. an incentive to get prescriptions filled at their local pharmacy was shown to increase prescribing of unnecessary medications: “doctors knew that prescribing antibiotics was unhelpful but were swayed by financial incentives.” Incentivizing patient outcome and minimizing resource utilization to get to that outcome needs to be a part of that. I have heard ideas such as providing clinics/physicians X amount of dollars per patient (likely adjusted for the complexity of a patient). Whatever is used for their diagnosis/treatment comes out of that pool and the doctor keeps the rest as salary. Some modified version of this would be something worth considering, however outcomes need to be included, otherwise you will have some providers just pocketing the money and providing poor quality care.
2. At this point in my training/career I can’t say I have a particular community of interest, so I don’t quite know how to answer this question. I am currently considering a fellowship in interventional and chronic pain management after residency, but that is quite a ways away and things could very well change. In that group of patients, community health workers would be very useful in spearheading patient follow-up contact, making sure the interventions are working as expected between visits, or assisting in coordination between providers, etc.
Dr. Kovac,
Very good point about media influencing the way we approach disasters. And in today’s click-bait headline, like-seeking social media culture, responding to a disaster is one of those things that will garner attention. Doing something to prevent a disaster is much less likely to, because, as you stated, there is less drama involved. And why do anything that won’t bring attention and praise? What a shame
Dr. Lee,
“Extensive international travel net established due to the globalization process of last decades has greatly enhanced the possibility of the spread of diseases such as we are observing currently. So, developed countries are not to consider themselves safe from the emergence of vaccine-preventable diseases.” Don’t we all wish this simple concept was not so difficult for so many to grasp these days.
Helping others is indeed helpful to ones self as well
1. This is a very complex question. Simply, I would say political stabilization and improvement of the basic health level through vaccinations, addressing hunger, etc. Political destabilization is a major cause for refugees to flee. As stated in the text, “large-scale displacement may expose populations to diseases to which they have no immunity or conversely, they may introduce diseases, like malaria, into previously non-endemic areas,” which further complicates the disaster. Improving the overall basis of health in any given population will increase their ability to withstand disasters that may come their way. Vaccinations would be one spoke in that wheel, increasing access to healthcare would be another, addressing malnutrition would be a third, among others.
2. It is not profitable in the short term. “Follow the money.” While it would be more cost-efficient long term, many people do not often believe that it is worth the cost beforehand, likely largely because they probably just don’t expect disasters to happen to them. In that case, the preparation materials would become a waste of money or time and effort. This has been put on large display multiple times recently with the Covid outbreak and the Texas electric grid. Funds were put elsewhere and there weren’t enough masks, etc. to fill the needs of the medical providers. Texas very rarely gets that cold, so some of the energy producing mechanisms were not functional because they were not engineered to function in that weather. Also, Texas has its own distinct grid to avoid taxes and regulations and was unable to get outside help. These seemed like good ideas, because they were profitable in the short term. But eventually the shortcuts came back to haunt.
I think Jennifer brings up a great point in her answer to question 2. Feedback from the local people that are receiving the help of these short term trips is particularly important. If they have a bad experience then they are unlikely to come back the next time there is another group, and will likely also tell of that experience, decreasing the likelihood that others will seek aid. That not only defeats the purpose of the trip, but may be completely counterproductive if the local people are not made part of the effort to improve. Their experience is one of the most important parts of the event and needs to be taken strongly into consideration.
1. I think one of the first things healthcare providers can do is to intentionally seek out experiences that put them in the midst of different cultures, so that they can have first-hand experience with a culture different from their own. Being told that this culture does things this way, or that culture believes that is fine and well, but not nearly as influential on someone as actually encountering those differences. And as the lesson mentioned, spending a short time in a different culture often causes an awe and appreciation for the differences, so in some ways, experiencing the different cultures for just a few days can be of great benefit for their realization that there is no one culture that is best or right, but that there is beauty in diversity.
2. It is very easy for short term trips to become closer to a vacation for those going than to be a mission to help those in need. One important aspect of short-term trips in my opinion is that there needs to be some form of long-term care as well. Diagnosing someone with hypertension or diabetes on a short-term trip is useless, and may even be psychologically harmful in the long run to someone if they are unable to seek follow-up treatment and maintain this chronic disease under good control. Partnering with a local clinic to fill in whatever gaps they may have in caring for the local people can be very useful if the trip members are coming to serve, and not to do what they want. This can be even more helpful if they establish a regular short-term trip, say annually, with specific goals to meet. Bringing in difficult to access medications, a specialty clinic, such as ophthalmology, or providing a small surgical center on an intermittent basis that otherwise these people wouldn’t have access to can make a huge difference to a community’s overall health and well-being.
Jasleen,
I agree with your point that we need to invest more into farming. My father in law is a farmer, and I recently worked with a woman who’s father was a farmer. He was in a ton of debt due to the costly investments needed to start and maintain a farming business, and every year had to increase his debt. The large equipment is expensive to buy and maintain, the seed, fertilizer and water are bought is massive quantities, and no one man can farm enough to support those costs, so farm aids have to be hired, which increases the financial burden even more. The people providing millions with food should not be put at such a disadvantage. Farming is a very difficult, demanding job physically and metnally. Tracking the weather to know when is best to plant, water, harvest, etc. there is a lot of science to farming, despite the “simple” monicker often given to agricultural workers. And the entire crop can be destroyed in a day with high winds, fire, or long drought conditions, wiping out their income for the entire year.
1. I think approaching nutrition from a more macroscopic level is necessary. Nutrition is much more than calories. It is apparent in wealthier nations that caloric excess causes its own issues, and focusing primarily on caloric supplementation without addressing the micronutrient shortages is increasing health problems in poorer communities. We have a relatively good idea of what a healthy diet consists of, so that needs to be what is implemented: less processed food and High fructose corn syrup, more vegetables with vitamins and minerals. Less simple carbs, more proteins. And these changes need to be a result of local and national investment into the agricultural department to promote higher levels of production of these products. Basic dietary education at young ages so that people are encouraged to make wiser decisions when given the choice is also important.
2. Self-centeredness. The best kickstart to address issues of poverty is for people with knowledge, skills, and resources to help fix the issues that plague the poor and vulnerable to use their knowledge, skills, and resources to start fixing the issues. Instead, people are largely focused on themselves (both on an individual level and a community level). This is quite reasonable in some instances, as well-resourced people still have problems to deal with, and so they are focused on addressing the issues that face them. However, there are so many who have very basic needs not being met, Well-resourced people and communities could band together to alleviate much of that burden without bringing harm to themselves.
*Note: I would differentiate self-centeredness from selfishness, as those who are selfish (in my personal definition, I suppose) are unwilling to help, while those who are self-centered are potentially willing to help, but just don’t realize there are needs they have the ability to meet, because they are focused on themselves and their own needs/desires.
Jennifer, I like your point about personal responsibility and prevention in regards to WASH/nutrition. While the local healthcare systems have a responsibility to their communities to promote healthy lifestyles in both regards, as well as educating why they are important, the last step always falls on the individual to practice them. A doctor cannot take the medication for the patient, the patient must do it themselves. In the same way, individuals must choose to practice the hygiene fo hand washing, etc. Hand washing is one of the simplest, yet effective ways to prevent infections and negative health outcomes, rich or poor.
In response to Dr. Kovac’s question 1)
I agree with your thorough description of what would work to improve system. It seems to me though, to be more focused on healthcare systems that are large and may already have some of these systems in place, or at least the groundwork for their implementation. What about small rural clinics, or villages without any true healthcare available nearby?
Your mention of the “train the trainer” program to me would be a good first step, but I think there needs to be a group of trainers that would essentially make up a mobile training event to spread the word not only to healthcare entities, but make it a public educational pursuit. Then mothers will be educated themselves and be better able to act as an advocate for their newborn children’s healthcare, or perhaps even provide it themselves.1. The HBB program, or something similar, should be a part of training for everyone that works in birth centers, regardless of their credentials. A vast majority of the time, simple maneuvers are all it takes to help a newborn initiate breathing, and anyone could be trained to do that. As stated in the paper, the skills were not retained well by many, so retraining on regular intervals, such as once a year, should prove to increase the likelihood that whoever may be present during a birth is capable of providing at least some basic interventions. It could even be effective to teach the entire community in areas of high neonatal mortality regularly how to do this, so that it becomes more of a wide-spread basis of knowledge.
2. WASH implements practices that reduce exposure to harmful infections. Nutrition promotion improves the diets of individuals. Both of these practices are very important for overall health and wellbeing, particularly in combination with one another. Someone who practices WASH will reduce their exposure, but it can never be totally eliminated. If that person has a poor diet, their immune system will not be particularly strong, and those times when exposure occurs, it is more likely to cause infection which can lead to harm. Vice versa, having good nutrition will allow your body the best chance to fight any infection that comes, but bombarding it with germs can still overwhelm it and lead to infections.
Kimberly, I am frankly surprised to hear of the volume of female patients you have had in the US even, that are essentially treated as 2nd rate, with lack of access to so many things we tend to take for granted, like reading. I would be interested to know more specifically the negative impacts these realities have had on their health. We can infer that the affects would be even greater in countries where women have significantly less say at a social level and a policy level than the US. Starting at the young age, as you mention, to bring about an understanding of equality would be essential to bridge this gap in care.
Nildia, I like your point that “displacement of people leads to overcrowding which increases the risk of disease outbreaks.” I had not considered this issue, but it would definitely be true. Masses would seek shelter in the nearest available less-dangerous area, which would significantly increase the number of habitants in a short period of time. They would also likely be coming from a variety of cities/areas and bringing the local germs all together in the same place to transfer to the other groups.