[Rebecca Mayo]

Nelson,

I agree that activating the learner is attainable in any setting. I found that when I was asked to see patients vs. solely observing encounters, I learned more quickly what I did and did not know. I also felt much more confident in taking action to treat patients when given these active opportunities to learn.

[Rebecca Mayo]

Question #1:
There are numerous barriers to the expansion of healthcare education and faculty development, especially in lower resource settings. Some of the most basic barriers are also some of the most detrimental. Firstly, if there is a language barrier, then it can make communication difficult between educators and learners. It can also cause misunderstandings and can lead to errors. Furthermore, there are different ideas across cultures about healthcare ideals, ethics, and limitations. It could also be difficult to gather enough people who want to be educators in low resource settings and could be difficult to gain the trust and interest of the local people as outsiders. All these barriers add to the difficulty of expanding faculty development in LMIC settings.

Question #2:

I think that kindling kindness is translatable in any environment, especially in LMIC settings. Showing our patients and our students empathy and compassion brings a human element to medicine and strengthens relationships. When working at my previous job as a scribe in the emergency department, I encountered many homeless, immigrant, and uninsured patients. One of the most memorable patient interactions I witnessed was when a patient had a significant skin condition due to being unable to shower for weeks because he was homeless. Generally, in these settings the patient would be given creams for his skin and told to go find a place to shower, and then discharged back to the streets. However, the physician I was working with contacted the nursing managers and arranged for the patient to be taken upstairs and allowed to shower and then was given new clothes. This amazing and simple act of kindness allowed this patient to have dignity and immediately begin healing. This moment was a powerful reminder of how much kindness plays a role in medicine.

[Rebecca Mayo]

Lauren,

I like your idea of supporting CHWs by honoring and elevating their position in the community. I agree that monetary support can be difficult in certain communities. It may be possible to require payment from patients through anything they may be able to provide. Like in the story of the Miskito people, some patients brought bananas as payment. This sort of payment from the community can increase CHW resources and could expand their scope of practice. I also think that the local or national government should recognize the critical role that CHWs play and should support their efforts monetarily as well.

[Rebecca Mayo]

Question 1: What additional elements would be necessary for universal health coverage to be effective?

As the article suggested, the issue is not necessarily the lack of access to care, but the poor quality of care received. There is a considerable lack of skilled physician care available to people who live in impoverished and rural settings. That is why it is imperative for the government and large organizations such as NGOs and the communities themselves to work together to implement quality, local, preventive healthcare, that meets their needs. Without top-down guidance, it is unlikely for healthcare to improve at all levels of care. There needs to be increased motivation from physicians, or other healthcare providers, to spend more time with their patients. This will improve health outcomes and education. There also needs to be motivation on the patients’ part to attend preventive healthcare screenings, so that disease can be stopped before it occurs. By improving the quality of care provided, focusing on preventive care, and improving patient education, universal healthcare could be much more effective.

Question 2: How could low-resource communities better make use of community health workers?
Community health workers have the benefit of understanding their communities and having already earned the trust of their patients. Due to this, the CHWs need to be better utilized to implement preventive healthcare. In resource-poor countries, CHWs are essential to the well-being of their citizens. The CHWs are assets that can be used to educate patients on abstaining from risky behaviors, can provide a safe space for giving birth, and can screen and treat preventable and common diseases. By providing government and monetary support to the CHWs, communities will be more resilient and better equipped to handle crises when they arise. The CHWs fill a vital role due to the lack of skilled physicians, and because of this they must be better supported to improve the health of their communities.

[Rebecca Mayo]

Lauren,

I agree that vaccination efforts need to increase prior to and after a CE has begun. I also like your idea of screening those who are trying to help during the emergency. I too find it interesting that those who are helping are sometimes the source for further suffering.

[Rebecca Mayo]

Question 1: What actions can healthcare providers take to decrease cross-cultural barriers?

The best thing that healthcare providers can do to decrease cross-cultural barriers is to educate themselves about the various cultures in their region. It would be wise to learn customs, beliefs about life, death, and health, and specific vulnerabilities for certain cultures. By arming themselves with increased awareness, healthcare professionals will be able to provide a better medical experience. This will also reduce misdiagnoses, misunderstandings, and increase compliance. Another way to become more culturally competent is to engage with the various communities. This could look like volunteering with certain organizations, serving at public health fairs, and advocacy for those who are of different cultures. By improving our own shortcomings first, we will be able to provide adequate examples of what it looks like to be culturally aware. This will give leaders of different communities the opportunity to teach us more about what we can do to improve their health status. Furthermore, it will provide an avenue for healthcare professionals to team up with local leaders for increased awareness and advocacy.

Question 2: What prevention interventions could best help reduce consequences of complex humanitarian emergencies?

Improvement in the fundamental functions of society will improve the well-being of their residents, and the resilience of the country. It is important to boost economic stability through diversity, develop adequate healthcare systems, improve agricultural practices, and improve WASH, among various others. By improving the population’s well-being and overall health prior to disaster events, the people will be more resilient, and the situation is less likely to devolve into a complex humanitarian emergency. Local and federal governments need to work together to reduce risk for crises. Furthermore, if there are already epidemics occurring, then those need to be targeted first through vaccinations efforts and improved access to care. The key to helping a country through a complex humanitarian emergency, is to prevent it in the first place.

[Rebecca Mayo]

Lauren,
I agree that providing more nutritionally dense, whole foods to impoverished families would radically improve global nutrition. I also agree that the price of these types of foods are often the barriers to obtaining healthier options. I like your idea of educating about what types of food provide health benefits and those that do not. I think it could also be beneficial to identify individuals in communities who could become farmers. Then these individuals could get even more education on economical and sustainable agricultural methods. That way food could be produced on a larger scale. The communities would benefit from increased access to whole foods, and the farmers could help boost the local economy.

[Rebecca Mayo]

Question 1: What actions are most important to improve global nutrition?

I believe that catching malnutrition at the earliest age possible provides the best outcome for impoverished nations. This starts with adequate prenatal care, so that mothers are nourished which will help to decrease infants with low birth weights and pre-term deliveries. This also lowers congenital abnormalities because providers will be able to supplement nutrients such as iron and folate at these prenatal care visits. It is also important to continue routine follow-up care for the mother and the child after delivery. That way the mother continues to receive enough nourishment to be able to do sole breastfeeding, and so that her child can gain weight healthily. By intervening early, children have a greater chance of avoiding malnutrition and the increased risks of becoming severely ill, having lifelong disability, and of dying.

Question 2: In your opinion, what are today’s greatest obstacles to progress in global health?

I believe that increasing wage gaps, gender inequality, and lack of access to healthcare and education are some of the biggest obstacles to progress in global health. The wealthier have continued to become wealthier, and the poor poorer. This only increases health disparities. The poorest people do not have the money to feed themselves or their children, cannot afford to miss work to seek out healthcare, and cannot afford treatment when it is needed. By encouraging economic growth and stability, there will be more opportunity for the impoverished to gain better, more fulfilling employment and thus bring themselves out of poverty. It will also increase the gross national income to rise, so that the countries will have more funding to provide public health initiatives for their citizens. Another obstacle is that women often do not have the ability to become educated or work, so they cannot contribute to the betterment of society. This is due to increased rates of contracting HIV, the prevalence of child marriage, increased rates of sexual and physical violence, and increased risk of maternal mortality. By protecting women, the whole country will benefit from the increased healthy citizens who can be productive members of the workforce. These women will also have the opportunity to become educated and have fewer, healthier children. Finally, a lack of access to healthcare and education puts current and future generations at risk, and perpetuates the cycle of poverty. If there is a global effort to improve key aspects of general welfare, then infectious disease rates will decrease, and the healthcare system can adapt to provide long-term preventive care.

[Rebecca Mayo]

Julie,

I really enjoyed your perspective on improving maternal healthcare starts with improving the well-being of women of all ages. I agree that women from a young age are disadvantaged as you suggested with disparities in nutrition, child marriages, increased HIV rates, and susceptibility to sexual and physical violence. All of these contribute to women’s health and by advocating for better and more fair treatment of women, the entire country will benefit. When women are treated as equal citizens they have a greater opportunity to become contributing members of society and have the ability to pass this on to their future children.

[Rebecca Mayo]

Question 1: What is the mechanism, in your opinion, through which WASH and promotion of nutrition complement one another?

Hand-washing and increased hygiene promote wellness through prevention of disease spread. In low-resource and impoverished countries, access to clean water and sanitation is often lacking. Because of this, community members have a higher chance of contracting infectious diseases, especially diarrheal diseases, that can be debilitating and fatal. Access to adequate nutrition is another important component of overall welfare. If a person is malnourished, they are more susceptible to disease due to immune suppression and will get sicker than a well-nourished person. Hand-washing, sanitation, access to clean water, and adequate nutrition all contribute to the spread of disease. Thus, it is vital for parents and community members to be educated on how to reduce the disease burden in their community by combining WASH techniques and maintaining appropriate nutrition.

Question 2: In your opinion, how should maternal healthcare be best expanded to protect women throughout their lives?

In many low-resource nations women have little control over their lives including their education, healthcare, and body autonomy such as reproductive rights. In many parts of the world, female genital mutilation is still routinely practiced. Strong global commitment is needed to stop this horrible practice so that women can have healthier genitourinary tracts and be able to have healthier pregnancies later in life. Protecting women through prosecution of sexual predators, genital mutilators, and child marriage are a few ways that countries can promote the welfare of their women. It has been shown repeatedly that a woman that can become educated has children later and those children tend to survive and be healthier. That is because the woman is given the opportunity to empower herself through earning a living and being educated on how to take care of her own body before and during a pregnancy. These women will then be able to pass on their knowledge to future generations. Because these types of drastic changes will take years to decades to implement, it is still important to educate and screen women at the community level. Screening women for HIV, STDs, cervical and breast cancers, domestic violence, and giving prenatal education are various ways to improve maternal health now. Providing comprehensive sex education, including contraceptive use to delay and prevent pregnancies, will lead to lower child mortality rates, and women will be able to choose when they are ready to have children. This improves the mother’s ability to take care of herself and her future children will undoubtedly benefit from this.

[Rebecca Mayo]

Lauren,

I agree that the stigma surrounding an HIV diagnosis is a huge barrier to adequate HIV control, especially in pediatric patients. As you stated, the shame of their diagnosis can prevent parents from treating their own HIV infections, and thus negatively impact their HIV positive children. I think a community-based approach could be beneficial in educating parents. Education for parents on how their children can lead full lives with appropriate monitoring and treatment, or die in a few short years, could have a real impact on improving adherence to follow-up.

[Rebecca Mayo]

1) Barriers against HIV control
Some of the largest barriers to worldwide HIV control are cost, differences in culture, and lack of access to care and education—especially for women. The HIV epidemic is one that affects all ages, all nations, and all genders. It is one that requires a global effort to fight. Given the manpower needed to fight this disease, there is a large burden of cost. Since the 1980s there have been significant improvements into HIV detection and treatment, and because of this many are under the impression that the epidemic is under control. However, large numbers of people are newly infected annually and only half of the population infected are receiving appropriate treatment. This means that the world needs to pool its research, its funding, and its resources to find better preventive approaches, such as a vaccine for HIV, faster. Another significant barrier is the fact that there are different cultural practices around sexual intercourse. Some cultures consider educating about and discussing safe sex practices especially taboo, which means it is easier for STIs to be transmitted in such populations. It is especially important in such countries to discuss the importance of teaching those infected with HIV on how to prevent spread. Community approaches are the best option to honor cultural differences and will be an effective way to reach the most people. The same community approach can be used to set up clinics to treat those who are already infected. That way a larger percentage of those affected by HIV can be treated with life-saving ART therapy. Also, in much of the world, women still do not have equal rights, equal access to healthcare, and are victims of sexual violence. The HIV epidemic unequally affects more women than men, and the greatest mode of transmission of HIV is through heterosexual sexual contact. This puts women at a greater risk for acquiring HIV and passing it on to any subsequent children. Increased advocacy for women’s health and rights throughout the world could make a huge impact on preventing HIV infection in women and children. HIV is a very complex disease that requires a complex, global, multifaceted approach. The only way for its eradication to truly happen is if the world makes it a top priority by funding research, community education on safe sex practices, and by advocating for women’s rights and safety.

2) Pediatric HIV
Unfortunately for children, they are at the whim of their parents or caregivers when it comes to their own healthcare. Because children are not autonomous, they are easy to lose to follow-up, especially if they are orphans of AIDS, if they live in poverty, if their parents have their own illnesses to deal with, and if they have other siblings. HIV is thought of as a disease of adults, so the lack of understanding and education is the first obstacle to prevention and treatment of HIV in children. Educating the public on the scope of the HIV epidemic would be a great service to the children who are infected. Education should start at the community levels and be taught in schools, churches, and healthcare facilities. Also including HIV screening in well-child healthcare visits, to test the children who are missed during pregnancy and birth, could jump start ART therapy for many children. I believe the biggest reason that HIV control in children is lagging control in adults is due to lack of continuous follow-up. Parents who live in poverty, may not be able to take off work, travel to, or afford healthcare visits for their children, especially if they have multiple children. Thus, funding programs that support impoverished families through government-funded healthcare could help relieve some of this burden. Giving parents six months’ supply of ART drugs could improve adherence to treatment and improve outcomes for children who cannot be seen more often. Finally, improving national surveillance of those affected by HIV can give real-time data on the parts of the country that need more support. These areas could receive more funding for screening pregnant women and their children, and keep track of which children received medications, and when was the last time they were seen by a healthcare professional.

[Rebecca Mayo]

Ashly,
I agree, that people living in poverty are already disadvantaged in many of the ways you specified. The crowded living and dangerous working conditions are definitely at the top of that list, and lead to easy spread of TB. I also agree that education on how TB is spread and advocating for better working/living conditions could go a long way in improving peoples’ lives and decreasing the spread of TB. However, your idea on providing troops to countries in turmoil could be beneficial in certain situations, but also troublesome in others. This is such a difficult topic, because of course as a developed nation we should want to send aid to countries who are suffering, but this is not always feasible or the right course of action. In some instances we could destabilize the area further, when our aid is finally removed, such as the crisis we are seeing in Afghanistan now. I think instead of sending troops to the area, it may be more beneficial to send humanitarian aid to areas who are suffering from conflict. This can include healthcare workers, volunteers, teachers, and others who can help to relocate and treat people who have been negatively impacted by war.

[Rebecca Mayo]

1. TB
Tuberculosis is spread via respiratory droplets, which puts certain populations more at risk for contracting the disease: such as those living in poverty. This is because impoverished peoples live in crowded conditions, have higher rates of HIV infection, are more likely to be homeless or incarcerated, have less access to healthcare, and less ability to comply with treatment. All these factors greatly increase the chances of contracting tuberculosis. Since screening PPD skin testing and QuantiFERON gold blood tests for tuberculosis infection are not regularly used in low-income nations, patients must wait until they have clinically active TB before they are treated. Treatment is difficult because of the long duration, which causes problems with compliance, and increases rates of multi-drug resistant strains of TB. Treatment has its own risks as well due to the severity of side effects of many of the antibiotics used. All these issues combined make equitable treatment and eradication of tuberculosis that much more difficult. I agree with the article that a united global effort to eradicate this disease is needed. There needs to be increased funds geared towards research for a tuberculosis specific vaccine, as the current BCG vaccine is not adequate. There needs to be more research into the treatment of MDR and XDR strains of TB. I think that any respiratory isolation that can be obtained for people with active TB infections would go a long way in controlling spread. This could include giving people short-term housing so that direct observed treatment can be achieved for a short period of time. However, since this is unlikely in a developing country, instead patients can be given a supply of masks to prevent infection of family and community members. Also educating patients on the importance of cough hygiene, hand washing, and medication compliance will also go a long way. Given the high incidence of deaths due to tuberculosis and co-infection with HIV, efforts should continue on educating the public on safe sex practices, abstinence from drugs, and safe health care practices to prevent HIV spread. Preventing HIV spread, will also help prevent the re-activation of tuberculosis in those with latent infections and lower overall deaths due to the disease. Since the disease burden of TB is so high in much of the developing world, it will take a multifaceted approach and a united global effort to make headway into lessening its hold.

2. Neglected tropical diseases

I believe that the developed countries of the world need to lead by example and renew their efforts to eliminate NTDs in their own countries. It is disheartening to know that countries with centralized healthcare have millions of people suffering from treatable and preventable diseases. In these countries, it is important to make sure that NTDs are accurately recorded, traced, and isolated. There needs to be enough funding in healthcare systems in communities to ensure that these people have access to clean water, shoes, and basic hygiene to largely prevent these diseases. These countries have the infrastructure and the funding to make a large dent in eliminating NTDs at home. Another intervention that I believe would be especially beneficial against NTDs is access to clean water for all. This is a lofty goal, but if achieved, could eliminate many of these NTDs and improve the livelihood of millions. This starts with education. Communities should be educated on the need to use latrines or other systems for human waste to keep water sources clean. Then there are low-cost ways to disinfect water such as UV light and boiling. If these simple steps were implemented in every community, even if they were forced to relocate due to conflict, then many of these infections could be avoided or even eradicated.

[Rebecca Mayo]

Lauren,
I agree that sustainable legislation should be one of our top priorities when it comes to food production. Often we see loss of crops from poor soil, pests, lack of irrigation, and many of these are consequences of environmental destruction. If we found better, more sustainable farming methods, then many of these obstacles could be eliminated. It would also be the most long-term solution. With better production methods, then supply can be more fairly distributed to those in food deserts, or in impoverished nations. Another idea might be to create campaigns within restaurants and other food service industries to promote and reward donation of extra food. It is heartbreaking to see how much food is wasted on a daily basis from mass consumption. With these rewards-based programs, then those with increased food insecurity might have a better chance of securing their next meal.

I also agree that inaccurate surveillance systems are a huge obstacle to measles eradication. I like your idea of increasing trust between community healthcare workers and the community that they serve. I think improved training of these healthcare workers could increase their success as well. Even designating a location within the community for isolating confirmed and suspected measles cases, could help stall the spread of the virus.

[Author]

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