So you want to volunteer abroad?

Ever since I decided I wanted to go into medicine sometime around the fifth grade, I knew that I wanted to use medicine as vehicle to get involved with international development and relief work. In high school, once the concept of traveling abroad to do volunteer work became more tangible, I found myself growing increasingly frustrated at the prospects of my international volunteering opportunities. Most organized programs came with a hefty price tag and without even a high school diploma, I didn't know how much good I could do. (Definitely didn't want to be that annoying American pre-med who spent $1,500 and two days getting to Nepal, only to stand in on an operation without even knowing how to read vitals.) Then, in planning the summer after my first year of medical school, I knew that I wanted to work abroad in some capacity and yet again, became overwhelmed with the opportunities and need, but frustrated with what I thought was my limited capacity to help.

For all the years that I knew that I wanted to serve abroad, but asked myself "how?" I have compiled a series of ways just about anyone, including the pre-clinical medical student, can get involved.

1. Just go. Whatever language skill you might have, whatever region of the world you may be interested in, find a reputable organization and go. Even if you think there's nothing you can do, once you become immersed in an underserved community, the need will present itself. And from my experience the summer after my M1 year in Yantalo, Peru, I found that just being in an underserved community allowed me to gain an understanding of their health and social structure as well as the role of volunteers. This is a highly valuable first step a student can take as part of a lifelong commitment to global health.

2. Educate yourself and spread the word. Make use of resources like the World Health Organization and World Health Report to keep up to date on global health issues. Why don't you mosey on over to http://www.who.int/en/ right now and make that your homepage? And, you know you post at least 18x a day on Facebook. Why don't you make at least one of those postings a week on a global health topic? I find that even for myself, I don't go through the news and journals as thoroughly as I would like, but when someone posts an article with interesting title on Facebook, I do go ahead and take a look.

3. Seek out foreign students and/or other students with interest in global health. Whether it's just learning about the needs of communities abroad or maybe hearing about your friend's uncle's neighbor who runs an NGO in Uganda, global health networking is an invaluable asset to learning about and becoming involved in global health efforts.

4. If you're at a place in your life where going abroad simply isn't an option, look to the need in your own backyard. Some Chicago neighborhoods have just as much or greater need than third world nations. If you are unable to go abroad for the next one, two, three or however many years, don't let the circumstances stop you from making strides. Start local, and you will definitely gain skills that you will be apply to apply in any health setting. For example, if you learn how health care is delivered in a local low-resource settings, you will undoubtedly be able to apply those same principles to providing care in low-resource communities abroad once you are able to leave the city limits.

I think my point here is- stop thinking and start doing. Your commitment to global health doesn't have to start with eradicating world hunger. Don't get too carried away and start now...even if it is just on Facebook.

Mental Health in a Global Context

When I think of global health, my first thoughts are of cholera epidemics, projects to provide clean drinking water, and undernourished children. However, with statistics indicating that in middle income countries depression accounts for twice the disease burden of HIV/AIDS and that in low income countries depression is almost as large a problem as malaria, it is evident that I am not paying enough attention to the impact of mental illness on the world at large.

The sad thing is, I'm not the only one.

1/3 of countries do not have a budget for mental health services.

This is a great disservice to the 15 million people estimated by the WHO to suffer from depression, the 26 million people with schizophrenia, the 125 million people affected by alcohol use disorders, the 40 million people with epilepsy, and the 844 thousand people who die each year from suicides. These people are not having their needs met.

During our seminar on mental health, we were led by Daniel Yang of Project FOCUS and Mary Black of the Heartland Alliance Kovler Center. They not only opened our minds to the immense disparities that exist in the treatment of mental illness, but also to the particular skills necessary to make a difference.

One of the skills emphasized should be quite familiar to individuals well versed in global health-- cultural competency. This is a phrase that often gets thrown around quite liberally when it comes to interacting with people of various backgrounds. However, it takes on special meaning when discussing the beliefs of a person from Senegal as to why they think they are experiencing epileptic fits or when attempting to counsel a woman who survived the genocide in Rowanda, but is now experiencing PTSD symptoms. An understanding of the language, the culture, the experiences of the people is necessary to make a difference. It is important not only in developing a therapeutic relationship with the patients, but also in ensuring that interventions do not bring additional scrutiny or negative consequences to an already vulnerable group. As future physicians and global citizens, our mantra must continue to be "first, do no harm."

So, for those of us who don't possess a background conducive to providing individualized treatment, there are still ways to help. One way is to "train the trainers" by providing education to members of the community so that they may serve as counselors and therapists. Secondly, people can serve as mental health advocates by increasing awareness of disparities in care and demanding that individuals with mental illness receive equal civil and political rights.

There are many ways to help, so start the dialogue and raise awareness of the disparities in delivery of mental health services!

Preventative vs. Interventional Global Aid

Mark Ward, the Acting Director in the Office of U.S. Foreign Disaster Assistance in the Bureau for Democracy, Conflict and Humanitarian Assistance was the speaker at one of our seminars that was very interesting to hear. Mark’s role and his department’s role is one of great importance in acute global disaster response. He provided some very chilling revelations about the nature of the situations that he has been experiencing with the department. The 2010 Haiti earthquake was a disaster that truly was a benchmark disaster for the response team. On the bright side, the level of response and aid was a record high; however, this was thrown into sharp relief by the sheer scope of the disaster, which also was recordbreaking. What Mark Ward touched on was the issue of preventative planning, and I’d like to explore this topic a bit further.

Just from a financial perspective, we have to consider what all goes into a barebones reconstructive effort—not only does physical infrastructure need to be rebuilt, from transport, housing, amenities, agriculture, to civil and legal structures that ensure a stable community. In addition, seed money must be poured into a community to jumpstart local activity—much like cellular processes, the macroscopic progress follows the microscopic changes. This doesn’t even include the maintenance care and infrastructure required to hold a displaced/refugee population while the main reconstruction is taking place.

Such a burden can be somewhat alleviated by preventative planning/maintenance. Unfortunately, this means an increase in basal activity costs, which from a policymaker’s point of view is not necessarily feasible. Or, as so often is the case, myopic leadership decides it to be wasteful spending.

But in a day and age where the costs of disaster relief and, as Mr. Ward stressed, the frequency of which are rising at an alarming rate, financing and planning with the least common denominator approach is irresponsible and increasingly costly in the long term.

Here in the United States, with our own insurance and health care issues reigning dominant in the medico-political arena, we see the implementation of screenings and preventive health care practices on the rise. Baby steps—yes—but essential to an increased level of community health in the long term. Small changes, for instance, dietary regulations in adolescent school children have ramifications down the road for rates of diabetes, heart disease, and obesity rates, if projections are to be trusted. Such small changes, with an initial financial investment can free up billions of dollars of money in the health care industry for better treatment and better outcomes. I use this analogy because it illustrates how a paradigm shift in approaching a problem can create a more responsive powerful system.

I’ve always been interested in the financial aspects of medicine, and it is true that each effort must be viewed individually to see which model works better—preventative care or intervention, based on the scope of the issue at hand. On the global level, disaster relief is similar—the spontaneity of some disasters requires interventional approach, however, much like the most recent Japanese earthquake, preventative investment was able to absorb and nullify a lot of what could have been catastrophic to a lesser prepared country. It is scary to imagine the humanitarian crisis that could have been, had not Japanese lawmakers and engineers had the foresight to build earthquake resistant structures.

With a new international crisis perpetually on the horizon, perhaps it is time to start applying a preventative approach more actively.

Me? Judgmental?

I try to live by one rule “be compassionate at all times.” This life goal has brought me to a place where I deeply value the idea of being as non-judgmental as possible, and over all I think I do a pretty good job of being open minded… But there is always room for improvement, since after all, we all judge. When I joined the GHLP one of my main motivators was that I felt I really needed to practice utilizing skills that would allow me to make sure my ventures into global health work would not put my own ideas and priorities first; that I would really be assisting a community gain well-being and health in a way that is continuous with their morals, ideas, social architecture, and perspective. I was concerned that because I THINK I’m trying to be non-judgmental I will miss that I am actually only seeing the picture through my own rose colored lenses or pushing in a way that I don’t realize is disrespectful.

Before the reproductive health seminar I experienced the bitter taste of what it felt like to realize I was truly and utterly being narcissistically judgmental. This humbling philosophical epiphany occurred while I was reading the USAID article about how the Extending Service Delivery (ESD) Project partnered with Basic Health Services (BHS) to train religious leaders to be a vital source of health education in Yemen. My immediate gut reaction was “No! Religion and medicine do not mix, they need to be separated like church and state!” But as I continued to read I realized that might gut reaction, was simply that, a visceral reaction. Maybe I have been conditioned to have that response to the idea of religion intermixing with large-scale projects at a countrywide level. After all, the majority of the public elementary schools I went to certainly beat the messages of the constitution into us. In fact… I don’t even think my childhood education ever included other countries governments or values into the curriculum… but that is a story for another day…

The truth is that in Yemen, and many other communities around the globe, the Muslim religious leaders are a vital and important part of the society. The citizens reach out to their leaders and deeply value their faith. If health education could be provided to the leaders so they could then combine it into their practice of community guidance, and the citizens and religious organizations were on board, isn’t this actually a gift, rather than a detriment?

Many citizens in this country live in communities that are very hard to get to and they don’t have easy access to health professionals or health education. Reproductive health education is extremely important in this country that deeply values fertility, and according to the USAID article “As of December 2009, religious leaders reached 644,413 people (515,320 male, 131,093 female) in five BHS governorates. Community meetings by inter-sectoral groups reached 110,287 in the same year, while newly trained community vol- unteers reached another 282,230 people, mostly women, within the first half of 2009.”

I was horrified at my judgmental first reaction, especially since this is such an amazing program with so much hope and potential success. But at the same time, I have been humbled and deeply value the awareness that comes from realizing you were judging something simply because you have been taught that its done another way in your own community. Clearly the goal of utilizing the resources and social foundation of a community, including religious leaders, to provide health education is a fantastic and effective path.

I’m sharing this experience with you, not to embarrass myself with a blog of my ridiculous judgment, but to remind you that we can all be gut-reaction opinionated, that is simply part of being human. But we also have the frontal lobe’s gracious power to evaluate all of our opinions and turn them in to positive educational experiences that will in turn help us help others.

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Thoughts from The Global Health Consortium at UIC

This past week UIC celebrated Global Health Day with its first annual Global Health Consortium. The conference was created by the Global Health Research Collaborative (GHRC). The aim of the GHRC is to combine resources and faculty from all professional colleges at UIC in an effort to better coordinate international efforts and academic research, as well as providing more resources for health science students to study and serve abroad.

One of the highlights of the evening was looking back at Haiti. The panel consisted of 2 academic physicians (both of whom have worked in Haiti, one who was a native Hatian), and a representative from a NGO. The mutually agreed problem in the health care delivered after Haiti’s earthquake was, as expected, entirely organizational. As I sat listening to the speakers’ experiences, I asked myself how can multilateral efforts be better organized in the absence of a functional government? While the instinct is to lean towards centralization (the WHO appears first to mind), perhaps that may not be the best approach. Geographic, technological, financial, communicative, and prerogative barriers would suggest that, perhaps its best to avoid excessive coordination. The alternative however, seems too brash. Where global collaboration and post-partisan do goodism is the de-facto environment, are we capable of drawing borders for the sake of efficiency?

How do we determine if an intervention abroad is ethical?

Just recently, as I was reflecting on what to write about as a response to our third GHLP session on “Primary Health Care and the Strengthening of Health Systems,” I read something that truly made me step back and think about how we evaluate the credibility and efficacy of health care interventions abroad.

On a recent AMSA discussion board, a medical student within our AMSA region posted an entry about an organization he and fellow medical students started in response to the disaster in Haiti last year (in fact, their organization is affiliated with the same medical school that pioneered AMPATH in Kenya that we focused on in our discussion for this session). The entry seemed benign when I first read it; it explained the program, described what they had done in the past year, and invited any interested medical students to get involved, donate, and spread the word. I was truly impressed- for anyone to initiate and undertake such a large project, let alone a group of medical students pressed, is remarkable. And to make an impact in Haiti so quickly after the disaster hit, mobilizing forces and getting people and resources to the area within a year, on top of that.

Then, another medical student posted a comment that forced me to look back and think a bit more about this program. He expressed concern and disgust at the group’s claim to join them and experience medicine in a setting unlike anything they would find in the United States. This, he claimed, was encouraging people to practice outside of their scope of training and unethical; utilizing a vulnerable population for the sake of bettering the medical students’ skills.

I think this example poses a lot of interesting questions about interventions abroad, many of those that we discussed during our discussion about AMPATH’s inception and the motivation behind its creation. How do we evaluate health care programs initiated in the US that are meant for developing nations abroad? Does the desire for the continued affiliation for medical students with a health experience abroad preclude it from being a moral and ethical program? Or do we need such an impetus to keep a program viable, bringing students and faculty to the site year after year, maintaining a steady flow of oversight and workforce?

These questions, no doubt, can be applied to many programs that have been created abroad, whether they be medical or providing another type of service. Of course, I'm sure many of us would agree that such a program is unethical if it was created for the sole purpose of giving American medical students unique opportunities to put on their resumes and applications and talk about on their interview trails. But I think we need to be careful in dismissing the credibility of a program because of the desire of students and institutions to get involved with experiences such as these. Without a motivation for a long-term partnership between a medical school and areas such as those in Haiti and Kenya, would such a program be sustainable?

Family Planning

In seminar #5, Yury took us through a few case studies on Reproductive Health and Family Planning. We also went through different scenarios concerning issues of family planning in the developing world, and discussed how we would approach these issues, keeping in mind context and cultural sensitivity. The most interesting message I took away from this seminar is how far-reaching and pervasive the effects of good family planning can reach. Proper contraceptive use, for example, will not only positively affect the health of the mother, but also ensures significant resources available for every family member to thrive. Essentially, proper family planning procedures ensures the health and livelihood of every single family member.

Moreover, proper family planning initiatives enter the realm of tackling social stigmas and cultural perceptions. If contraceptive use is generally frowned upon in a society, couples will be far less likely to use it or seek out alternative options. In addition, if getting an abortion carries a stigma in a society, it is far more likely for women to attempt unsafe self-abortions. These issues are among the multitude that can be addressed in a particular society to try to normalize family planning procedures and educate couples on all of their options.

Finally, another important point addressed by the seminar was the importance of including men in the conversations on family planning. This is an aspect of family planning often overlooked, but it actually quite important. If men are educated on the benefits of proper family planning—especially the impact on the health of their wife—they would be far more likely to agree with complying. Men’s compliance is vital for proper family planning to work successfully, and it is important to address them specifically in family planning initiatives.

For more videos about the impact of family planning please visit: http://www.pathfind.org/site/PageServer?pagename=WalkWithUs_video

World Bank and IMF

Angel's Seminar was helpful at introducing the goals of the World Bank and IMF and the various economic theories used to try to attain them. I am looking forward to learning more from the seminars series. I found a brief 7 minute BBC video on examples in recent history of how The World Banks strategy has backfired and actually created more Poverty in many countries across the globe.

http://www.youtube.com/watch?v=DrynBzUpyag

9 AM

Women & Global Health

When we discuss aspects of global health and define the problems that exist, we must always remember that each and every barrier to health that exist is that much higher for women. HIV, malnutrition, endemic tropical diseases. Women not only suffer from these diseases right alongside the men, but they also face the complications of repeated pregnancies which further increase their mortality rate. Not only are they facing the health risks associated with reproduction, but they also often lose the chance to receive an education and establish any independence.

Hundreds of thousands of women die each year in developing countries as a result of pregnancy-related complications. Millions of women want to delay or completely avoid pregnancy but are unable to due to lack of access to effective contraceptives or the inability to make the decision for herself to use contraceptives. Adolescent girls face repeated pregnancies beginning at an early age and often miss their opportunity to, at best, finish an education, or to even survive childbirth or worsening malnutrition and make a health transition into adulthood.

While working in Ghana several years ago, I participated in a community outreach program that involved traveling by foot through villages and administering Depo Provera shots to women while their husbands were working in the fields during the day. These women would be waiting at the road on the first Monday of every 3 months, desperate to receive their shot and have the comfort of knowing that they had prevented a pregnancy for another 3 months without their husbands' knowledge. They were able to sleep peacefully at night without worrying that their husband will refuse to wear a condom, will feel the bumps of Norplant in their arm or the string of an IUD in their uterus, or find a packet of pills.

It seems that the international community has recognized that in order to meet goals such as improving worldwide rates of malnutrition or decreasing poverty, women's reproductive rights must be protected and access to reproductive health care needs to be readily available. Once this crucial goal can be met, women will be able to contribute to their societies and, most importantly, will suffer just a little less.

Patents

Courtesy Yousuf Ahmed:

So in the beginning of our last GHLP session (sad day), we saw a video on a alternative system to the current patent system. Right now, if a pharmaceutical company develops a drug, it patents said drug for a specific amount of time, usually between 6-20 years, which means that no other pharmaceutical company may manufacture said drug or research on said drug without a license to do so. It’s a way to reward inventors for their hard work, yet this practice has come under fire for stifling innovation, creating unreasonable barriers to drug availability through high prices, and the overall lack of new medications.

What this patent pool tries to do is fix these disparities, specifically with respect to HIV medications in Africa. A patent pool is a sort of sharing agreement between companies, meaning that the companies can cooperate and use otherwise unavailable drugs and research in order to develop new treatments. For HIV specifically, this can mean that new combination medications can be developed so rather than taking 3 pills at a time, one can be sufficient, or that new children centric medications can be researched. And for the inventors, they are paid a fair royalty for using their work in new applications, new drugs. Sound perfect right? What reasonable individual could say no to this?

Pharmaceutical companies for one find it easy at times to say no. Why? I can’t really say for certain, because I’m not on the board of a major pharma house, but in my experience working at a small pharma company the reason that drives most of these companies away from such a power sharing agreement is just that basic idea, they have to share power. Corporations exist to serve their investors, and they do that through the accumulation of power and wealth. In their eyes, the patent pool is a move away from that basic idea, for the patent pool would cut into their profits and increase their competition. There is no perceived benefit in the eyes of the company.

So how could a patent pool be attractive to the companies involved? One benefit is by decreasing the cost of research through increasing cross talk between different companies, previously underserved markets can open for better business exposure. Innovation increases as patents become open, look at the patents on the steam engine where once the patent was lost and the field opened, innovation dramatically grew. And with all this cooperation comes the fair royalty payments, meaning while the companies wouldn’t be getting as much as they could with a normal licensing deals, they would still be compensated at some level for their product. And finally, while I made a effort to explain that corporations have no real need to act morally, at the end of the day a corporation is made up of individuals, and it is through these individuals that we can change our view on global corporations to one that is more ethical and moral.

http://www.youtube.com/watch?v=Vj0dbFgjoh4