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Dawn, we both highlighted the importance of kindness. Of course, knowing the kindness of God in our lives makes all the difference for us and the way we approach people. But all people are made in God’s image and can appreciate the value of kindness. Certainly we have all experienced kindness toward us at some point. But if it isn’t valued highly, then other motives and values can so easily push out kindness. The ultimate fix for that is a change of heart that only God can make. But I agree that to some degree kindness can be taught by modelling, at least if there is some softness of heart which I think is true for most people (to varying degrees!). And this is true not just for students working under us, but sometimes for colleagues and other co-workers. I have 2 surgical colleagues who are much younger and while good surgeons they do tend to have less compassion. And so I think about ways that I can model kindness and gently challenge them to be more compassionate and forgiving toward patients. One day in the not too distant future I’ll be retired and they’ll be looking after my patients, and maybe even me!
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?
All of them! None of the 8 habits of exemplary clinical teaching outlined in this article are dependent on technology or other resources found only in high income countries. Clinical skills, clinical reasoning, patient care, kindness are needed wherever healthcare workers are treating and caring for sick people. So thinking out loud, activating learners, listening smart, keeping it simple, wearing gloves (ie being hands-on), adapting to the unexpected, linking learning and caring, and kindling kindness are required of all clinical teachers of any health discipline, anywhere.
I don’t have a lot of opportunity to teach as we only get medical students with us for perhaps an average of 4, maybe 6 wks/yr. And they are generally shared among 4 surgeons. Some of these habits I need to develop more than others. I do tend to think out loud somewhat which I hope is helpful. Also, I try to demonstrate genuine caring and kindness which I know is not always practiced, and to discuss with students the value of relationship with patients and the fulfillment found in those relationships.Dawn, I read with interest your comments about CHWs in varying areas of SA, some being well supported with clear roles and responsibilities and others not. It really highlights the importance of government health authorities investing in this level of healthcare which has such potential for improving the overall health of the population. Reading this article and spending time thinking about it has really helped me to appreciate the need for this. They still need people like me to remove their acute appendixes (if they can get to a functioning hospital) but there are so many more people affected by conditions that could be prevented or managed by CHWs, with far greater overall impact.
Question 2: How could low-resource communities better make use of community health workers?
My previous attempt to answer the original question 2 reflected my confusion around the phrase “your community of interest”. This re-worded Q2 is more clear.
We have considered some of the tensions that exist in choosing where to invest in healthcare, one of which is community/primary health vs secondary and tertiary care (eg surgery). But it has been shown that while all levels of health care are obviously needed, the most bang for the buck with regards to population health outcomes is found in primary and preventative health care. And because family doctors are far less available and accessible in low-resource communities, the obvious solution is to invest in well-trained, supported and resourced community health workers. It is far cheaper to train and support them compared to doctors and they will impact far more people. So accredited training programs are needed with standardized graduation requirements. And then appropriate remuneration must be guaranteed, reflecting level of training and responsibility, without gender bias. Continuing health education for the CHWs will be needed along with some accountability and periodic assessment. Well defined support lines are needed to help with more difficult situations. Continued maintenance of supplies/resources needs to be ensured. A simple but effective health data management system also needs to be developed and maintained, ideally regional or even national. And the CHWs need to be integrated into the health system as it exists in the region, working as part of a team, and contributing as they are able, to the planning and implementation of health services.Dawn, you make some interesting comments about the difficulties encountered dealing with displaced people, especially if they are trying to hide, but the need to still ensure prevention interventions are being applied (i.e., vaccinations). I imagine that many displaced people don’t know their vaccination status (like here!) but of course don’t have access to any health records, unless they have personal health records that they keep themselves and think to bring with them when fleeing the complex emergency situation. So that becomes a problem knowing who to vaccinate. Not sure how to solve that one. But it makes it all the more important to push vaccine programs before the emergency, as you emphasized.
Q2: Prevention interventions to reduce consequences of complex humanitarian emergencies?
The answer to this question is obviously different in many respects to the same question applied to natural disasters, where mitigation strategies can be applied to specific types of disasters. And because complex (humanitarian) emergencies (CEs) involve human conflict and aggression, local government is often dismantled or at least preoccupied and not able to properly address the humanitarian needs resulting from a CE. Also, these CEs often occur in countries with pre-existing unstable governments and power struggles where prevention strategies for anything may be difficult to implement. But the following may be worth considering:
1. As argued in this article, aggressive efforts to properly immunize populations at risk will help to reduce disease outbreaks, since the majority of outbreaks (70%) are vaccine preventable.
2. Other interventions to improve the overall health of the at-risk population will improve their resilience (improved nutrition, clean water, proper sanitation, access to health care and better disease management, etc, etc.).
3. Efforts to reduce poverty and improve standard of living and to empower women will reduce the overall consequences of any crisis, emergency or disaster.
4. Improvements to infrastructure (roads & bridges, electric power, communications, etc.). Of course these may be compromised in a CE, but the more infrastructure that remains intact, the easier it will be to respond to situations.
5. Ensure international agencies have detailed and practiced response plans for CEs as well as stockpiles of supplies that would be needed.Q1: Actions to decrease cross-cultural barriers?
1. Take advantage of cultural competency training opportunities, particularly those directed towards your unique setting.
2. Research the culture(s) you commonly encounter. Learn about beliefs, especially health related, attitudes, gender roles and expectations, food, religion and special festivals, common health problems, etc.
3. Access professional translation services when language is a barrier. If not available, beware of limitations of using untrained, non-medical translators. Be sure you are being understood (and that you understand). Use illustrations or other aids as needed.
4. Try to learn a few key phrases in the foreign language you commonly encounter (primarily to break down relational barriers and hopefully encourage trust).
5. Beware of stereotypes. Don’t pre-judge people based on race, ethnicity, etc. But rather, seek to counter those stereotypes and give the benefit of the doubt.
6. Be on the lookout for mental health issues that may negatively impact care, which may be expressed differently or may be hidden.
7. Always show respect, don’t rush, and expect to learn from them.Thanks for your thoughts, Dawn, which you have described well. I share your struggle with regulation of nutrition, at both ends of the spectrum. We walk through supermarkets here in the west and see all kinds of processed and junk food. We go to restaurants and see lots of unhealthy choices, and know that even the more healthy-looking choices wouldn’t look so healthy if we went into the kitchen and examined the ingredients! I go into my hospital cafeteria and watch health care workers (nurses) eating a plate of French fries with gravy and melted processed cheese for lunch (yuck!). How do we stop them? We have to respect and defend freedom to choose. But why can’t the government enact laws that force food producers to meet healthier standards, both food sold in stores and food prepared for immediate consumption (restaurants)? We can’t prevent people from making unhealthy food in their homes, but as you say, we can educate them a lot better than we have. My kids (in their early-mid 20s) can’t eat sweet foods without hearing at the back of their minds what I drilled into them: “sugar is poison”! The better we educate the more it will effect us. If we could address food like we have addressed smoking, I’m sure it would be more effective. The situation in the developing world is certainly more challenging but the availability of junk and processed food is a big problem there also, and so the same recommendation to regulate food quality, limiting these options, can be made.
Q2: Greatest obstacles to progress in global health?
A late and brief answer (sorry Dawn!).
This is a very broad and huge subject! I’m not sure how to order them in importance, but the list does include poverty, corruption, conflict, gender inequality, natural disasters (eg drought) and climate change, lack of education, increasingly sedentary lifestyles, obesity and associated metabolic disorders, persistent high rates of infectious diseases (although considerable progress has been made). This list is obviously high level (and incomplete). Each of these issues can be further explored as they have been in our studies so far, but the connection with global health is fairly clear.Q1. What actions are most important to improve global nutrition?
There are multiple threats to proper nutrition can be seen on a global level as well as regional and local. These include climate change, which according to this article is projected to reduce global crop production by 10% by 2050. This is a massive threat! Other threats include 1) unsafe food production processes which increase the risk of infectious or chemical contamination, 2) poor/inefficient agricultural practices yielding less crops, 3) inequitable food distribution globally, 4) threats to fishing including over-fishing, ocean waste, etc, 5) excess junk food production and consumption, 6) armed conflicts which displace people and destroy infrastructure and agriculture, etc. Another big factor is gender inequality where women are not educated about nutrition nor empowered to provide. And of course poverty is a huge problem affecting so many areas including nutrition.
The Sustainable Development Goals do address many of these threats. Clearly, actions to reduce climate change are critical and are being addressed albeit with limited success so far. Poverty is a difficult problem to solve but progress is being made and must continue to be made. And then actions to improve food production (farming and processing) will make a big impact. This needs to include ways to reduce production of unhealthy foods. Also, education about healthy eating habits and proper nutrition are needed globally, in both wealthy and poor nations.Response to Dawn’s Q2. I agree that changing “maternal” health to mean a mother’s health throughout her life is difficult. Probably best to leave maternal health as it is and continue to promote it. But pursuing “women’s” health opens it up to all aspects of a woman’s health, across all ages. The idea of promoting “men’s” health and “women’s” health is interesting. Of course there would be a huge amount of overlap (heart disease, diabetes, HTN, lung ca, etc, and all the infectious diseases). In the west, men’s and women’s health refers to health issues unique to each, but perhaps in the developing world where attitudes to gender are much different, it might work on a broader scale. I wonder what workers in these areas would say about this?
I suspect that transgenderism is far less prevalent in the developing world so shouldn’t be a significant factor. Let’s hope it stays that way!Q2: How should maternal healthcare be expanded to protect women throughout their lives?
Because of the increasing burden of non-communicable disease, and the success of maternal health initiatives, there needs to be a shift to address these other health issues. There is still much work to be done in maternal health, especially in sub-Saharan Africa, so we can’t afford to pull back investment here and lose hard won ground. However, recognition of the changing disease profile in low and middle income countries needs to lead to research in how to address this. Screening for common cancers (breast, cervical) and diabetes and HTN, etc, along with an effective program for managing these conditions would go a long way to improving women’s health and therefore societal health. Of course many of these efforts will include men also since they are also affected by these conditions, but part of the approach requires promoting gender equality more generally so that women are educated and empowered, and can access these programs and receive the care they need.Q1: Mechanism by which promotion of both WASH and nutrition complement each other?
WASH (WAter, Sanitation and Handwashing) interventions and promotion of nutrition are both health interventions with the same goal: better health, with a reduction in illness and all that goes with it, potentially better cognitive/mental development, and improved quality of life and possibly standard of living. Each without the other will fall short in achieving these goals. And so both must be addressed and could often be addressed together in combined educational and promotional initiatives. Also, WASH is obviously an integral part of safe food preparation so has a direct connection to promotion of healthy nutrition.Q2. Why is HIV control in children lagging behind that of adults? How to fix?
While MTCT is theoretically easy to eliminate, there are still many challenges to doing so. For many reasons, pregnant women may not present to get proper health care, or HIV testing and treatment may not be offered or available. Infants who do acquire HIV may not be diagnosed. In west and central Africa, only 10-30% of infants have access to early diagnosis, and only a small portion of them get treatment. And then children who get sick may be tested and treated for TB or malnutrition, etc, but not tested for HIV. Also, in families where there is HIV, all family members are often not tested, so the children are missed.
In addition, HIV progresses more rapidly in children so there is less time to get them on to ART. They are dependent on a care-giver which may be lacking as many have lost one or both parents. And pediatric medical services are often less available or over-stretched.
So attention is needed to address the above issues, bringing HIV testing to all pregnant women in high risk areas, providing early infant diagnosis programs in all these areas, ensuring testing for family members of affected individuals as well as for difficult to reach children (orphans, street kids, etc.). Education of health care providers re HIV in children is crucial, as is the training of additional pediatricians and pediatric nurses, etc.Q1. What are the largest barriers to worldwide HIV control?
As detailed in the article, HIV control refers to the reduction in HIV transmission, bringing the disease incidence to a locally acceptable level. This is in contrast to HIV elimination where HIV incidence is reduced to zero. This is a reasonable goal when considering transmission by MTCT (mother-to-child-transmission) and blood transfusions, due to availability of routine testing and the close connection to the health care system. But elimination is not a reasonable goal for transmission due to sexual activity or IV drug use. So what are some barriers to achieving disease control with respect to these modes of transmission?
1. Dangerous sexual behaviours. Changing people’s sexual behaviours is a complex challenge. Promoting monogamous, lifelong sexual relationships is the ideal, through example, through spiritual transformation, through sweeping changes to societal norms and morals, etc. This seems an unrealistic goal for whole nations or regions, at least in the short term. But promotion of these ideals through educational material in schools and media may help. Efforts to reduce transmission by using condoms, making them easily available and promoting their acceptability are important, as are the promotion and provision of male circumcision. The use of PrEP by high risk groups is another helpful tool. All of these require commitment and investment by the local government, and provision of resources by international agencies.
2. Poverty. Like with so many health challenges, poverty is a major factor when it comes to HIV. It may lead women into prostitution, access to health care may be reduced, attention is diverted to sustaining life (ie getting food), education is lacking, and unsafe IV drug use is more prevalent, etc. All of these increase the risk of HIV transmission or late diagnosis or failure to remain on ART.
3. Clearly there are many other barriers, including lack of resources, the challenge of asymptomatic infection, the stigma of the diagnosis, etc.