Building Sustainability through Short-Term International Projects: Ethical Issues in Global Health Work

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Building Sustainability through Short-Term
International Projects Ethical Issues in Global
Health Work

• Parmi Suchdev, MD, MPH
• Epidemic Intelligence Service Officer
• Centers for Disease Control Prevention
• PEM Fellows Conference
• November 15, 2006

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Objectives

1. Importance of global health work
2. Ethical challenges principles for short-term
   trips
3. CHIMPS as a model
4. Challenges
5. Resources

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State of global child health

• Worldwide, 11 million children younger than 5 die
  each year1
• Most from preventable or treatable diseases
• Widening gap between the wealthy and poor
• 3 billion people live on less than 2 a day2
• Mortality rate in sub-Saharan Africa was 29x
  higher than industrialized nations in 20001
• U.S. accounts for nearly ½ of worlds spending on
  health, yet it ranks 27th in life expectancy2

2Bezruchka, Sickness and Wealth. 2004
1Staton, Pediatric annals. 2004
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Causes of under 5 child mortality, worldwide
WHO, 2004
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Child health in the U.S.

• Only 3 of the worlds 2 billion children live in
  the U.S.
• Leading causes of mortality in U.S. children ages
  1-4 years
• Accidents (unintentional injuries)
• Birth defects
• Cancer
• Assault (homicide)
• Diseases of heart

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Why care about the health of children in
developing countries?

• Changing demographics of U.S. practices
• Increasing immigration, adoption
• Increasing travel to developing countries
• Educational benefits
• Cost-effective, humane way to help other
  countries achieve long-term stability
• Moral duty
• AAP motto dedicated to the health of all
  children

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Recent literature on working overseas

• Duffle Bag Medicine
• JAMA, 2006
• The New Medical Missionaries- Grooming the next
  generation of Global Health Workers
• NEJM, 2006
• A Successful International Child Health
  Elective
• Archives, 2006
• Volunteering Overseas- Lessons Learned from
  Surgical Brigades
• NEJM, 2006
• Issue on Ethics of International Medical
  Volunteerism
• December AMA Journal of Ethics

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International health training during residency

• Over 38 of graduating US and Canadian medical
  students participated in an international health
  elective in 20001.
• Early exposure to international health during
  residency promotes continued participation in
  volunteer activities after graduation2.
• Capitalizing on residents enthusiasm and
  idealism!

2Thompson, et al. Academic Medicine, 2003.
1AAMC, 2000
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Educational benefits of international health
electives

• Improve clinical diagnosis skills
• Knowledge and training in tropical medicine
• Attitudinal changes
• Public health service, cross-cultural
  communication
• Recruitment to residency programs

Thompson, et al. Academic Medicine, 2003.
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Educational benefits of international health
electives

• Introduction to international health
• Introduction to new or rare disease
• Reciprocal relationships with participating
  international institution
• Opportunities for language immersion
• Service and social responsibility

Federico, et al . Arch Pediatr Adolesc Med, 2006.
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International volunteer work for practicing
pediatricians

• No set guidelines or norms
• Most are short-term volunteer brigades or
  training electives
• Huge variation in credentialing, clinical duties,
  language requirements, religious affiliations,
  costs, etc.
• No standard of care for trainees working
  internationally

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International Emergency Medicine
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Is international medical work ethical?

• Medical Tourism
• Short-term overseas work in poor countries by
  clinical people from rich countries.
• Are reasons people engage in international work
  humanitarian or self-serving?
• Is the objective to provide mere band-aids that
  fail to address root causes?

Bezruchka, Wilderness Environ Med. 2000
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Principles of an ethical international trip

1. Mission
2. Collaboration
3. Education
4. Service
5. Teamwork
6. Sustainability
7. Evaluation

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What is CHIMPS?

• Childrens Health International Medical Project
  of Seattle
• Founded by Un of Washington Pediatric residents
  in 2002
• Organize annual one-week outreach trips to rural
  El Salvador, focusing on public health education
  sustainable medical assistance
• Ongoing alliance with a local NGO physician

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CHIMPS Impact

• Promote opportunities for international
  experience during residency
• Recipient of 2004 AAP Anne E. Dyson Child
  Advocacy Award 2005 Dyson Community Pediatrics
  Training Initiative award
• AAP I-CATCH Grant!

http//depts.washington.edu/chimps/
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Principles of an ethical trip

1. Mission
2. Collaboration
3. Education
4. Service
5. Teamwork
6. Sustainability
7. Evaluation

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Review Organizations Mission

• Defines core purpose and groups collective
  beliefs
• Religiously affiliated?
• Government involvement?
• Address public health needs of community?

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CHIMPS Mission

• To ethically address underlying health issues
  and to provide sustainable public health
  interventions and medical assistance for
  underserved communities in developing countries.

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Principles of an ethical trip

1. Mission
2. Collaboration
3. Education
4. Service
5. Teamwork
6. Sustainability
7. Evaluation

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ENLACE

• To Link
• Enhance collaboration between existing
  organizations improve access to technology
• Health initiatives
• Water systems, health clinics, medical brigades,
  nutrition programs, indoor air quality
• Local physician
• Health committee
• http//www.enlaceonline.org/

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Principles of an ethical trip

1. Mission
2. Collaboration
3. Education
4. Service
5. Teamwork
6. Sustainability
7. Evaluation

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Educating ourselves

• Sociopolitical context
• The community
• Medical Spanish
• Local medical problems
• Effective interventions

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Where do we go?
Los Abelines
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El Salvador U.S.
Population 6.5 million 293 million
Life expectancy 71 yrs 77 yrs
Literacy rate (adults) 79 97
Infant mortality rate 33 7
Under 5 mortality rate 39 8
GDP per capita 2,080 35,060
The Official Summary of The State of the World's
Children, UNICEF, 2004.
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Los Abelines community profile

• Located in Morazan Department
• Focal point for 12-year civil war
• Population 1804
• 61 lt age 19
• Economic productivity
• Coffee, beans, corn, chickens, pigs
• Clean water shortage, no electricity or roads,
  few latrines, 30 homes straw
• Illiteracy rate 70

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Educating ourselves

• Learn local language
• Understand local medical problems
• Dental health
• Intestinal parasites
• Nutrition

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Researching effective interventions

• Fluoride varnish1
• Reduces caries
• Effect most pronounced if no other fluoride
  source
• Empiric periodic deparasitization2
• Every 6 month treatment reduces ascaris
  hookworm infection
• Prevention of malnutrition and anemia
• Iron supplements3
• Prevents loss of estimated 5 IQ points and 10
  learning capacity
• Universal supplementation in young children and
  women of child-bearing age
• Ongoing strategies for preventing iron deficiency
  preferred

2OLorcain, Parasitology. 2000
3Yip, J Nutr. 2002
1Marinho, Cochrane Database. 2005
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Educating others

• The community
• Health talks (charlas)
• Our peers
• Publications, speaking opportunities, etc.

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Principles of an ethical trip

1. Mission
2. Collaboration
3. Education
4. Service
5. Teamwork
6. Sustainability
7. Evaluation

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Service Doing work that the community needs and
wants

• Clinical medical care
• Linking the community with the local physician
• Public health interventions

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Clinical medical care

• Consultas/patient visits
• Most common acute illnesses include parasitic
  disease, malnutrition, upper respiratory
  infections, gastroenteritis, and a variety of
  skin diseases
• Donated medications and supplies per local needs
  WHO drug donation guidelines

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Bienvenidos a la clinica!
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Gathering health statistics
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Things we can treat
Tooth abscess
Impetigo
Scabies
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The difficult cases we cant
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Public health interventions

• Dental Health
• Education (charlas)
• Toothbrushes
• Fluoride varnish 3 times/year
• Intestinal Parasites
• Charlas
• Empiric treatment 2-3 times per year
• Complement community efforts to build latrines,
  provide clean water
• Nutrition
• Charlas
• Iron supplementation
• Community garden

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Applying fluoride varnish
Now you try it
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Best brusher competition
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Teaching the teacher
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Building confidence
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Charlas in action
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Principles of an ethical trip

1. Mission
2. Collaboration
3. Education
4. Service
5. Teamwork
6. Sustainability
7. Evaluation

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Teamwork

• Our medical education model

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The Original Dream Team, CHIMPS 2003
CHIMPS 2004
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CHIMPS 2005
CHIMPS 2006
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Principles of an ethical trip

1. Mission
2. Collaboration
3. Education
4. Service
5. Teamwork
6. Sustainability
7. Evaluation

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Sustainability building capacity

• Working in a single location
• Teaching the Teachers
• Augmenting existing systems of care
• Respecting cultural norms

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Principles of an ethical trip

1. Mission
2. Collaboration
3. Education
4. Service
5. Teamwork
6. Sustainability
7. Evaluation

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Evaluation

• Needs assessment
• Identify areas for intervention
• Clinical studies
• Define extent of problem
• Determine efficacy of interventions

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Iron deficiency assessment

• Iron deficiency is the most common nutritional
  disorder in the world
• No local estimates of disease burden
• Goals
• To estimate prevalence of iron deficiency in los
  Abelines and associated factors
• Implement targeted interventions to treat anemia
• Teach local healthcare workers to measure iron
  deficiency and follow anemia trends in community

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Iron deficiency assessment

• Methods
• Used donated hematofluorometer to measure
  capillary stick ZPPH
• Measured anthropometric indicators, diet history,
  physical exams
• Preliminary Results
• N338 volunteers
• Ages 6 months 89 years
• 102 cases or 30.2 iron deficient
• lt1 serving of meat or green vegetables and lt2
  servings fruit consumed per week

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Challenges

• Overwhelming need
• Impact on other cultures, economies, and
  environments
• Sustainability
• Access and Equity
• Meeting expectations
• Logistics

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Impact on other cultures, economies, and
environments

• Exportation of value systems
• Accentuation of disparities in resources,
  material wealth
• Medical waste
• Creating a perceived need
• Inappropriate technology

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Foot bridge project in Los Abelines, 2005
Total cost 10,000
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Sustainability

• Personnel
• Resources
• Institutional support
• Hospital and University
• Department of Global Health
• Partnerships
• AAP Section on International Health
• Local MOH

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Access and equity

• Structural determinants of health disparities
• Closing the gap of inequality
• Advocating for the rights of children
• U.S. only nation not to sign UN Declaration of
  the Rights of a Child1

1Kasper, Ped Annals. 2004
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Resources for finding volunteer sites abroad

• International Medical Volunteers Association
• http//www.imva.org
• AAP section on International Child Health
  Directory of Overseas Opportunities
• http//www.aap.org/cgi-bin/overseas/aapartcl.cfm
  
• International Health Medical Education Consortium
• http//www.ihmec.org
• American Medical Student Association
• http//www.amsa.org/global/ih/ihopps.cfm
• Health Volunteers Overseas
• http//www.hvousa.org
• Medics Travel
• http//www.medicstravel.org
• International Healthcare Opportunities
  Clearinghouse

Norton. Ped Annals, 2004
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Summary

• Child health is a global responsibility!
• Short-term international trips can be done
  ethically.
• CHIMPS provides a model for international
  initiatives that can be replicated at other
  residency programs.

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The Pediatricians Gift
-- To touch the life of a child
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Project Participants
CHIMPS Pediatrics Residents Parmi Suchdev, MD MPH Kym Ahrens, MD Ellie Click, MD PhD Mollie Greves, MD Heather Silverberg, MD Kelly Evans, MD Esen Garner, MD Crystal Benson, M Kim Johnson, MD Wes Diddle, MD Malaika Little, MD Kristina Toncray, MD Sabrina Guse, MD Mikelle Bassett, MD Erica Freeman, MD Viju Soma, MD Pediatrics Faculty Ellie Graham, MD MPH Cor Van Niel, MD  Maggie Wheeler, MD Nancy Danoff, MD Christina Pease, MD Family Medicine Julian Perez, MD Internal Medicine Oscar Zepeda, MD Angelina Labella, MD Physical Therapist Genevieve Hicks, MSPT Social Work Linda Reyes, MSW Nurses Jennifer Gould, RN Blanca Drumm, RN Shannon Chappon, RN Elizabeth Karmen, RN Lisa Marie Mesa, RN Julie Sharples, RN Others Debra Weissman Rajni Gunnala Chris Williams Elena Villata ENLACE Lori Macklin Chris Macklin Alfredo Aguilar Doris Evangelista de Leon Sonia Rodriguez de Rosales Alexendra Yarosevich David Mcgee Walter Bolanos Rodriguez Dr. Mireia Salazar Dr. Glenda Henriquez Perez Dr. Mirna Garcia NU-AID Julie Piskur, MD Leslie Ramirez, MD Greg Brisson, MD Medical Students Kevin Gobeske James Wysock Katie Chell Adam Romeiser Juan Ambrose Insua Vivien Leung Sara Boblick Los Abelines Health Committee Blanca Rosa Villalta Dalila Amaya Rosa Membreno Fide de Paz Reina Franco Mercedes Portillo Celio Andrade Patrocinio Villalta Humberto Martinez Nelson Paz Aristedes Pineda Anibal Reyes Miguel Angel Pineda Santos Guzman Rosalina Portillo Olinda Parada Yanira Orellana Adelina Pineda Vilma de Prarada Victorio Paz Vicente Guevara Enrique Cabrera Avelar Jose Vicente Moreno Flor Parada Reina Martinez Julia Medrano Zulma Pineda Juan del Cid
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