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Q2 – Which habit is translatable to education in LMIC? p709 articulated what for me is the most important element of education around patient care – “Link learning to caring.” In my experience teaching med students in the ER and overseeing paramedics, I felt a tension between the learners’ goals to learn about and rule out rare conditions (i.e. what tests to order); have a “story to tell” about a particularly interesting case; or perform procedures well. These are very different from the main concerns of the patient, who just wants to be reassured that serious conditions have been ruled-out, and most importantly, to feel better. I then developed a teaching strategy which is definitely translatable to an LMIC setting: 1) Rule out serious conditions with available testing 2) Help the patient feel better with available medications. As a specific example, a patient – say 40 years old – presents to the ER with chest pain. The provider wants to rule-out rare life threats like MI or PE, but the patient wants to know what is going on and to feel better. I would teach the learner the importance of getting an EKG, a troponin level, and a D-Dimer – to rule out the life threats, but I would make sure to also help the patient feel better; perhaps the history suggests that the pain is really due to reflux, so I would order Pepcid or a PPI in addition to ruling out the life-threats.
I have applied this strategy in resource-limited settings as well – in the setting of a mission cilnic set up at a local church, with only a stethoscope and baggies of pre-packaged medicaiton, if I obtained historical clues that symptoms of chest or abdominal pain were maybe due to stress/anxiety, I could prescribe whatever SSRI, or even Benadryl, to help with the symptoms, while using my clinical experience to rule-out the life-threats. If I had a learner in this setting, I would stress the importance of making sure that the patient’s goals for seeking care (normally to feel better/symptom control) align with my goals of providing great care (by training, often involving ordering the right tests and considering rare diseases). Or as the article summarizes:
“link learning to caring.”Q1 – Barriers to expansion of FDP in LMIC settings. I believe the biggest barrier surrounds the contextualization process. Not reviewing the curriculum, the outcomes support that the 2 year training program often launches the Health Worker into positions of leadership. Taking for example a low-resource setting such as a village, Health Workers are often already a leader in the community; having the worker leave for more of a national role would ironically be a possible “brain-drain” for that community. Additionally, the leadership model or philosophy may not translate to the new setting; (notwithstanding that a strong Wi-fi connection is needed.) My only experience in health education in rural Guatemala revealed that the American Missionary physician trained local health workers more like a master with apprentices; for example the leadership model of the curriculum may not translate easily into this low-resource training model. Finally, I would imagine that completion of the two-year training program is a major commitment; I would be curious to see data ragarding a “drop-out rate”, stratified against the resources/GDP of different communities.
Q1 – Barriers to expanding FDP in LMIC. Silas and Roxanne both rightly point out that funding is an evident barrier in low and middle income settings. It is very insightful additionally that Roxanne pointed out the potential language barrier as a barrier to expansion of the program, which is largely being presented in English. It would seem that translating the curriculum into local languages would be an important part of contextualization to the new setting. This becomes circular though, as it would seem that translating the curriculum would require funding, which is least available in the areas the education is most needed.
I appreciate that you pointed out that CHW’s are at risk of poverty. This is a bit of a tragedy, as – according to what I have learned – CHW’s are often the most motivated and connected members of a community. I agree that it is vital to budget for compensation of this very valuable resource when considering a public health improvement initiative.
Question 2: What actions could improve CHW career prospects? According to the article, CHW’s feel underappreciated and underpaid. (p4, p3.1.2) There are also apparently community individuals/leaders who are very motivated to serve in the role, but do not have the “credentials” obtained through training opportunities – (p5 3.2.2 – valuing lived experience above formal experience). It would make sense then that allocating money to pay a stipend for the valuable service of the CHW is a very important “line item” when considering financing a community health improvement initiative. Credentials perhaps could also be easily obtained online in our post-COVID, cell-phone connected world. (From my experience, I can now recertify my ACLS via online modules; and I have a colleague who is getting a philosophy degree from Univ of Ariz all online). Perhaps there is a way in our now very interconnected world to provide online training which could quickly train and then vett/approve potential candidates for community service, and then also provide promotion opportunities.
Q1 – Additional elements necessary for effective UHC. I agree with the article regarding the importance of “enhancing individual responsibility for health” (p7), as I believe this is perhaps the most important element. In a resource-limited system such as health-care, it is necessary to minimize each citizen’s demand on the resource pool in order for there to be enough for the entire population. In my career in the ER, though, I have seen poor lifestyle choices or preventable mishaps (i.e driving while intoxicated) consume tremendous healthcare resource. Individual responsibility bridges the gap between a person’s right to make life-style choices and the proposed right to healthcare with no financial burden. I am very skeptical that there is a remedy for this dilemma or that UHC is possible, but potential soltions would be: 1) legislate incentives for healthy life choices. (I believe AUstralia provides free gym membership to its citizens and provides tax incentives for various health goals like not smoking). 2) Stratify health-care utilization according preventable vs non-preventable event (??) – for example generate a bill for an intoxicated person coming to the ER for care while not charging for delivery of a baby.
Briefly mentioned was the fact that there is a deficit of millions of health-care workers – human resources for health – who are needed to provide UHC (p8). UHC is an unusual human right among other human rights, as it requires a tremendous human work-force to provide it. (The same argument could be made for universal education as a right, requiring educators to assure it.) This brings with it the tremendous complexities of education, and incentivization/compensation of the human work-force providing the care.Silas, I love how you point out the need to cultivate attitudes and behaviors, as its own skill-set for learners. Best-practice attitudes are often not inherently present (how do I say that nicely ha!), but certainly can be learned. I agree that cultural sensitivity and insights will only improve care and strengthen the relationship with patients, which in itself creates its own feedback loop that leads to better compliance with recommendations and better outcomes.
#2 Preventative interventions. What a difficult problem, as wars cause disruptions at so many levels. Table 4 in the article gives several recommended actions, some of which would be easier to execute. I believe building robust health infrastructure – clean water, vaccines, and vector control – will provide the biggest buffer for the destruction caused by war. It would seem like the international community would then need to be aware of regions that are heading towards armed conflict, to prepare with additional safety nets of refugee capacity, trained health and emergency response staff, and data collection.
From this posture then, some specific examples of ways an educator can help learners reduce cross-cultural barriers is summarized nicely in the article: through curriculum development and informative lectures; case studies and resulting discussion; and even role playing. Having been in community practice for most of my career, I would also add that modeling respectful treatment of all cultures during every patient interaction is noticed by the other health staff and potential learners – even in a busy ER – and can be formative in the way they will treat patients in their roles.
#1 Cultural competence. This paper was a little hard for me! It’s tricky when a prosperous culture wants to bless a less prosperous one. A rejection of the resoure could be seen as ungrateful; but the trained/sacrificial provider – likely giving up time at home with his/her family – wants to do his or her best for a marginalized community, and is willing to do it. I don’t feel like this paper effectively expressed this dilemma. I think this is most eloquently expressed in the Bible in John 5:5, where Jesus, led by by the Holy Spirit, ministered to just one man at the Pool. (This shows that our effectiveness can be defined by just helping one person.)
Silas makes a very insightful and important point that disparities in access to healthcare is a huge barrier to improved Global Health. He astutely points out that access to even basic healthcare services needs to be a starting point, irregardless of socioeconomic status or location.
Q2: What are today’s greatest obstacles to progress in global health? I appreciate this paper’s concise and well-organized presentation of a very robust and extremely complicated data set. I believe it high-lighted one overarching obstacle is that subsequent improvements will need to be highly individualized across very different settings. (For example: smoking cessation in some countries; life-style modifications in aging wealthier countries; and continued efforts to improve neonatal care in Sub-Saharan Africa). Individualized solutions are more difficult to execute from a global perspective I would think.
Another barrier is that DALY’s which are due to an aging population and chronic medical diseases represent problems that have either logistically difficult or resource-intensive solutions. (For example, chronic kidney disease, CHF and COPD are disabling even with advanced medical care; and heart attacks and strokes require time-dependent endovascular treatment in extremely sophisticated centers to avoid morbidity).
The article also hinted that gains in some “basic” illnesses like TB, neonatal syphilis, and HIV are starting to erode due to lack of funding and attention. A third barrier then would be to overcome the temptation to become “complacent” or divert funding to more complicated systems and solutions.Q1: What actions are most important to improve global nutrition? The article mentioned in several places the importance of closing “data gaps”, and I propose this as the most-important first step, in order to then have data-driven interventions. Apparently, data regarding basic food intake is sparse and often needs to be extrapolated across heterogenous populations, leading to inaccurate conclusions about adequacy of food intake. This effect is also seen in micronutrient deficiency estimates, as well as when attempting to make conclusions about people living in rural environments. Perhaps an initiative which made use of a community “healthy diet” champion could provide more granular and comprehensive data. This data could then be funneled into the nearly universal availability of cell phones; for example a community health worker could sample food and micronutrient intake for many of the community’s families and then load this information into an app-based national or even world-wide database to help guide policy.
With better data, guidelines can be revised with the current landscape of emerging research, micronutrient and host factors in mind. Guidelines can also be more tailored for a region, ethnicity, or community. Finally, the network of local health workers with a cellphone-connected set of guidelines, perhaps also with national/world-wide funding efforts can be used to deploy new interventions quickly.I feel that this paper tackled a very ambitious topic wow! It identified several issues as hindrances to maternal health, including rural residence, community views of the role of women, religion, and access to healthcare. Most of these barriers have very difficult solutions and interventions. Based on the other material from this week, I think the most powerful interventions would include introduction of community health workers (who apparently will need to be women in Muslin communities) and government-based education campaigns.
Question 1: I think the two most powerful pathways for improving infant growth in impoverished communities would include a physiologic/biologic solution as well as a socioeconomic one. 1) Encourage breastfeeding. The nutritional benefits are so clear, as well as providing benefits of nurturing/bonding and immunologic benefits. 2) Empower women. Women have many barriers to thriving, including insecure men as husbands; lack of education; lack of opportunities to generate revenue (exemplified by Prov 31); abuses, etc. I believe God’s plan for each woman is to be queen of a realm and a legacy, as illustrated by the book of Ruth. Once a family – and then a community – embraces this truth, the children will thrive.