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Hi Betty,
I appreciate you bringing up limited access to conferences. Many conferences are physically located in the western part of the world and are inaccessible to faculty from LMIC settings. This also reminds me how the WHO hosts their meetings in Geneva and set health priorities for LMIC but healthcare leaders from these countries are often underrepresented because of travel cost and inability to obtain visas from Switzerland. Dr. Pai from McGill School of Global Health discusses this visa issue in an article he wrote for Forbes titled “Passport and Visa Privileges in Global Health”. Similarly, he has discussed a toolkit to help decide if a conference would be more beneficial if held in-person or virtually. Virtual and reduced cost options should be available for faculty in LMIC.
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?
The article discusses “push” vs “pull” approach, noting the importance of LMIC initiating the collaboration by pulling in the resources and expertise of the high-resource settings. The pull approach takes more into account specific needs and cultural environment, this does mean that the initiation itself can be a barrier if not prioritized/ recognized as an opportunity or if there is a lack of trust between the two. Of course, low resource settings also struggle with access to technology, books and resources that help with faculty development. To have faculty development would also mean to recognize that the teacher based approach of lecturing and student memorizing which is very common in LMIC could need adjustment, this again would require a cultural shift in education.
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 believe all of the clinical teaching methods in the article are translatable to education in LMIC. In particular, I think kindle kindness and linking learning to caring can change the toxic culture of medicine often encountered by many students and educators that contribute to burnout and cause learners who once were passionate students into jaded providers. I think listen smart, thinking out loud, and wear gloves are very good ways to promote clinical reasoning and physical exam skills. From my own experience, I recall a patient on my neurology rotation as a medical student who for the better part of a week, we were unable to find a diagnosis for her sudden loss of function on bilateral lower extremities. She went from walking to 2/5 motor strength. At one point, we were asking her family members to bring in all supplements she consumes and a water sample from a well nearby their home. The patient was older and had dementia, she would sundown in the evenings and nurses were always very frustrated with her aggression. My attending one day, came in the morning, sat bedside and took a cloth and wiped her sweat off her forehead, and just looked her in the eyes and had a very human to human conversation. Although we did not have an exact answer prior to discharge, the course of her hospital stay changed significantly after that interaction and both her and her husband were so grateful towards us. It really taught me about the healing power of connection and touch, that although we may not always the ability to fix or stop our patient’s suffering, we can share in their journey and pain and offer some relief. As a second year medical student, seeing an attending “wear gloves”, set a tone for the type of human connection and interaction I would aspire to have as a physician.Hi Karla,
I appreciate the point you made about knowledge not being enough, we need to emphasize listening to patients and spending time. It does make me reflect on why this isnt a given because I assume those who are drawn to medicine care for patients and want to provide good care so what are some of the barriers that make this difficult? They noted several healthcare workers spend so little time with patients and see few patients, why is this? Are they working other jobs or where does the rest of their day go? I would be interested in hearing what the barriers are to providing more patient centered care in these areas.
Question 1: What additional elements would be necessary for universal health coverage to be effective?
The article notes a knowledge action gap as well as this a gap between formal education and knowledge. Addressing both of these gaps requires addressing quality of care. The article notes a study where doctors and nurses were given the same checklist items but there was not a significant difference in performance. We need to standardize requirements for medical training, for example ACGME in the states has specific requirements for training programs. We should have similar bodies in each country in order for a medical school to qualify as well as more standardized testing measures. To address the knowledge action gap we should have algorithms to provide evidence base care and spend more time providing direct patient care. This also means addressing the payment structure to move away from fee for service towards quality metrics.
Question #2: How could low-resource communities better make use of community health workers?
I think this starts with recognizing the importance of community health workers because this will affect mindsets and funding priorities. In order to do this, we would have to start with small projects and use research and data on the beneficial effects of CHWs to then expand access. This also involves engaging the community on how to utilize and access these resources and the direct benefit it will provide them.Hi Jacob,
I appreciate your point on open ended questions. I think this is something we are all taught early in training but tend to use less frequently in practice when feeling pressured with time management but this is especially needed when we are unfamiliar with our patient’s culture to reflect an open mind and non-judgmental or presumptive approach.
Question 1: What actions can healthcare providers take to decrease cross-cultural barriers?
I think the first step is awareness. Simply being aware and educated that cross cultural barriers are likely in a particular physician patient interaction can cue the physician to spend a few extra minutes in the room or be prepared to spend time building rapport with the patient. Of course, when language barriers exist, it is crucial to utilize a medical interpreter for effective communication and again be aware on the best use of an interpreter, for example speaking directly to the patient and not saying “please tell the patient..” and also being aware of body language and seating positions when the provider, interpreter and patient are in the room.
Question 2: What prevention interventions could best help reduce consequences of complex humanitarian emergencies?
The article discusses different types of emergencies including conflict based complex emergencies and natural disasters. For complex emergencies, they found chances of an outbreak occurring to be higher than natural disasters largely by vaccine preventable diseases so based on these findings vaccinations would best help reduce the outbreaks found in these emergencies. Of course, as we have discussed previously, there are many barriers to vaccinations including cost, infrastructure, and vaccine hesitancy. In addition, once conflict is occurring, vaccination campaigns can be dangerous with several health care workers killed in conflict regions. Overall, conflict regions tend to deteriorate over time so the best strategy would be to identify and target the high risk areas as soon as possible.Hi Jacob,
Thank you for including some resources in your response, I was unfamiliar with Ecosia! I also like how you addressed solutions already being offered, which I agree have been necessary and consequential. I wonder what you consider the governments role to be in this area. I also wrote about conflict as the greatest obstacle but seeing that number, 1.26 trillion dollars really makes you think how much good could have been done with those resources.
Question 1: What actions are most important to improve global nutrition?
The article references how nutrition will require a multidisciplinary approach to improve nutrition noting that simply increasing caloric intake will lead to increased burden of malnutrition through obesity and its downstream effects. The multidisciplinary approach includes addressing agriculture and global warming through our greenhouse effect, improving food safety by addressing contaminated foods that result in diarrheal to cancerous conditions, to the content of the food itself to avoid high caloric but nutrient deficient meals. The article discusses how this goes beyond governmental responsibility. I personally, disagree with this. I think most of the efforts thus far have been driven by NGOs and private corporations as donations but we need to hold governments more responsible. These problems while may go beyond governments, absolutely require more government input, funding and regulation in order to make changes. For example, the pesticides used in agriculture, require governmental regulation. Our governments should work to make us healthier as a priority. The article discusses the factors need to improve nutrition but unfortunately does not offer many solutions, I think in part because we still havent discovered these solutions.
Question 2: In your opinion, what are today’s greatest obstacles to progress in global health?
I think the greatest obstacle is conflict. We have seen time and time again how countries can get destroyed during conflict, setting back that society for generations leaving trauma, broken homes and insufficient infrastructure. We see countries progress economically, socially and then fall back with conflict. We see countries destroyed with mass exit of refugees and inability to rebuild and continued decline. We have learned that the greatest loss in armed conflict is not through the war itself but through malnutrition and poverty that results. It becomes a cycle that leaves hopelessness and causes ‘brain drain’ which further affects the country. People start to resign to the idea that their country will always be corrupt, at war, and with little to no hope or opportunities. Its hard to discuss issues of education and economic progress when you worry about the day to day survival.Hi Khanh,
I appreciate how your response requires accountability of the social hierarchy but also provides a good solution of improving trust in marginalized communities.
You mentioned Muslim women not having the ability to make decisions in any life choice. This is one thing I struggle with in the academic world as it describes Muslim. While it is true that Muslim women with fewer economic resources and lack of education live with more oppressive environments, it is not because of their religion. It is because of the cultural teachings in that environment that are often covered with religion. I mention this because you bring up the good point of general public attitude towards Muslims which is an important factor in why many Muslims are continued to be persecuted and oppressed around the world, its why we have sympathy for Ukrainian refugees but not Syrian refugees at our borders. I think the academic world has to do a better job of differentiating culture from religion to prevent further stereotyping and misconceptions that are harmful to Muslims. This will also help empower Muslim women in those environments, if they were to learn about their own religion and its teachings regarding health, education, women’s rights. They would be more empowered, but the general perception fits their cultural teachings and they assume it to be true themselves.
Question 1: Which, in your opinion, are the two most powerful pathways to improving infant growth in lower income communities?
According to the article, most of the pathways did not show strong evidence for improving growth on their own but there were several limitations to the study and I think this provides support for the need of a multifactorial approach. I think two of the most powerful pathways are WASH and women empowerment. When women are education, have a greater say in making household decisions, their children do better. Combining education with access to basic necessities can greatly impact a family. If a women is education, she is likely to have a smaller household, provide more individualized care to her children, seek medical health sooner for serious conditions, seek learning opportunities regarding parenthood/breastfeeding/ nutrition for her children. Some of the limitations to empowering women, include the lack of sanitation, inability to access menstrual hygiene products which prevents many girls from going to school and responsibilities of finding clean water for their families several miles away. I think the pathways need to occur in tandem for the best outcomes.Question 2: In the context of India, what are potentially the most powerful interventions to broadly improve maternal health?
Specifically for India, I feel there needs to be a cultural shift in order to improve maternal health. In my clinic in Dallas, I have seen infants who recently relocated from India, and when reviewing their birth history I question why they had a c-section and I was told ‘If you go to the hospital, they are likely to do a c-section for extra money’. I spoke to a few of my attending physicians who have an Indian background and they agreed its a common practice in certain hospital to extort patients for money. Even if this were to happen in one hospital, mistrust spreads very quickly and prevents patients from presenting to the hospitals or trusting healthcare workers in general. I was sadden to see that Muslim women were less likely to seek care compared to other religions. I think the caste and discrimination system in India plays a major role in this but I also think lack of education significantly impacts culture and view of religion. Islam empowered women 1400 years ago at a time when there was no other system in place, religious or not, to provide women the rights Islam gave them. Its sad to see women relinquish their rights simply because they are not aware of them. Part of being religious, especially in Islam, requires a commitment to learning and education. Overall, as I mentioned in the first question, education has a huge impact on health in general and will improve maternal health but for India specifically, I think a cultural and political shift is also needed to reduce discrimination and extortion when seeking care.Hi My,
Thank you for bringing up the point of identifying the missing cases of TB. I agree we need to focus on this. I can see how increasing rapid diagnostic services can play a role in finding some cases, but I worry many missing cases are patients who will not be presenting to health care services to begin with. I think we should probably consider more mobile clinical units along with the rapid testing to reach more people.
Question #1: From your perspective, why are people living in poverty most likely to suffer from TB, and how should this fact influence efforts to control the disease?
People in poverty have limited access to resources, healthcare and are often living in crowded, unsanitary spaces. People in poverty are also exposed to malnourishment and poor air quality which increase risk. Given TB is tied to poverty, controlled the disease would involve addressing socioeconomics and preventative efforts targeted in these regions like the vaccine.
Question #2: What, in your opinion, are two interventions that would be most effective against neglected tropical diseases?
Neglected tropical diseases occur in specific climates and are linked to poverty. The link to poverty is both a risk factor in acquiring the disease but also a vicious cycle as the NTD leads to significant disability that removes children from schools and adults from work. I think two interventions include improving basic water supply and sanitary infrastructure which will help reduce disease transmission.Hi Savannah,
I agree with you and also discussed vaccine hesitancy. Thank you for the reference articles. I appreciated your last sentence that discussed just how many factors really play into overcoming low resource settings. It really goes to show how many factors interplay with each other and are not in isolation. Similar factors play a role in food insecurity as do in settings with weak health systems. Good way to tie the articles together.
Hi Khanh,
I appreciate the point on food preservation. It would be a good way to reduce waste, I think one thing to consider is how do we preserve food that doesn’t contribute to disease in the future? For example, after WWII food rationing became a priority in the West which resulted in shelf stable canned foods and other food high in calories. Our shelves havent changed much since then and we now find these foods contributing to cardiovascular risk. With crop preservation specifically, we aren’t worried about the food not be healthy but it just makes me wonder how do we preserve it and will there be additional risk from that?
Question #1: What system-wide changes, in your opinion, would most successfully increase world-wide food security?
I believe to improve food security we have to change our priorities and values as a society. This would then translate into our public policies and regulations. For example, the article mentioned how conflict regions account for 50% of the food insecure population. When we review the historical context of why many of these areas are in conflict or countries of low resources, it involves exploitation by the resource rich countries for further natural resources. These resource rich countries then also create the non-profit organizations and drive the NGO’s who’s develop the priorities on solving these issues. We are often left divided on the solutions because we want the best of both worlds. For example, avocado farms often leave the land dry and have created water shortages in the local population. These avocados are then all exported to wealthier nations. Similar situations exist for many food products, as we are seeing with India’s rice production right now. We want to keep providing in a way that prioritizes profit but hope that we can also create sustainability to avoid food insecurity. Within the states, our funding priorities do not reflect values of health nationally or food security abroad, so we rely on the non profit organizations to solve these issues that would require legislation.
Question 2: What do you believe are the most substantial barriers to global measles elimination, and how can these be overcome?
I think the high herd immunity is definitely a barrier in our global society with frequent travelers as well as vaccine hesitancy and resource availability in some areas. I will speak more to the vaccine hesitancy as this is what I see affecting measles in the States. I think promoting primary care in general will help with vaccine hesitancy and combat misinformation. Patients are trying to make the best decisions for themselves and their children, misinformation can spread alarming information that would cause understandable hesitancy. This along with the reduced trust in healthcare providers results in overall hesitancy, we need to re-establish relationships and rapport. See our patients as wanting the same goal as us and speak to them from a place of scientific knowledge combined with an empathic approach and delivery. We need to re-develop more open lines of communication where patients aren’t afraid to ask and voice their concerns to their providers due to fear of being judged or dismissed. When we improve primary care relationships and promote the importance of regular primary care visits for overall health, we can address measles and other conditions.