A collaborative planning grant sponsored by the Medtronic Foundation in partnership with the

1. Consortium on Health and MobilityA new paradigm for medical education in the global villageFebruary 24, 2010 A collaborative planning grant sponsored by the Medtronic Foundation in partnership with the University of Minnesota and HealthPartners February-November 2010

2. in a mobile world, everyone is at new kinds of risk, and the old categories of immigrant health, tropical medicine, and international health are obsolete. • we are stronger and faster at educational best practices if we work collaboratively A new paradigm for medical education in an era of global mobility:

3. Case study 76 yo Hmong man from Xiang Khoang Province, northern Laos. US arrival 1990.

4. Case study: globally mobile populations CC: “Kuv muaj teebmeem ua pa” HPI: Patient with known COPD for 10+ years, Followed in outpatient clinic on inhaled steroids and beta agonists. Recurrent exacerbations of shortness of breath treated with antibiotics and steroids as an outpatient. Intermittent mild eosinophilia noted (ANC 600-700) Admitted from clinic with 2 weeks of worsening dyspnea and new RLL infiltrate

5. Case study: globally mobile populations ROS: Moderate anorexia, 10 lb weight loss over past 2 months. Mild upper abd distress after meals. Vague, diffuse bloating, intermittent. Active medical problems: Diabetes type II, controlled on oral agents Gout with mild CRF Nephrolithiasis Hepatitis B carrier, diagnosed 1990 after US arrival, followed with LFTS/AFP q 6 months, RUQ US annually. HBeAg (-) and low viral load

6. Case study: globally mobile populations PMH: 1991 - Hookworm and strongyloides noted on US new arrival screening. Treated with mebendazole. Soc Hx: Soldier during US secret war in Laos. Swam across Mekong River to Thai refugee camp in 1979 and stayed in Thailand until US resettlement in 1990. Married, 8 children. Habits: Opium and tobacco use in Laos; opium addiction treated at refugee camp; quit smoking tobacco before US arrival.

7. Case study: globally mobile populations Exam on admission: Asian American male, moderate respiratory distress BP140/90 P 100 RR20 T99.5 O2 sat RA 94% HEENT: Pharynx nl, no adenopathy Lungs: diffuse inspiratory and expiratory wheezing Heart: JVP nl, distant HS, no m,g,rub Abd: soft, mildly hyperactive BS, no hepatosplenomegaly, masses. Labs: Wbc 11.2 Hgb 13.0 Plt 397Diff: N 65% L 16% E 7% (AEC 784) M 1% LFTs normal Electrolyes: NA 136 K 4.0 creat 1.4 BUN 35 CXR: RLL interstitial/alveolar infiltrate

8. Case study: globally mobile populations Admission diagnoses: COPD exacerbation with community acquired pneumonia (Strep pneumo/H flu/mycoplasma) Abdominal pain, weight loss in hepatitis B carrier: DDX: peptic ulcer, liver cancer, TB, “other parasites that cause abdominal distress?” 3. Mild renal insufficiency

9. Case study: globally mobile populations Treatment: IV steroids, oxygen, albuterol nebulizer q 4 hours, ceftriaxone and azithromycin

10. Case study: globally mobile populations Day 2: Called to see patient for confusion PE: Unresponsive, agitated. BP90/50 P120 RR24 T40 pO2 88% on RA Neck stiffness noted Lungs: diffuse rhonchi, expiratory wheezing Abd: decreased breath sounds, soft, no rebound, no organomegaly

11. Case study: globally mobile populations CXR: New bilateral infiltrates. Repeat CBC: Wbc 18.3 Hgb 13.0 Plt 397Differential: P 75% B 10% L 5% M 6% E 0%

12. Case study: globally mobile populations Dx: sepsis due to bacteremia from community acquired pneumonia vs urinary source LP: cloudy spinal fluid, 8,000 wbc/mm (nl 0 - 5). Blood, urine, spinal fluid all revealed gram negative rod. Blood cultures within 18 hours (+) for E coli.

13. Case study: globally mobile populations Patient deteriorated despite intubation, pressors, IV steroids, antibiotics and fluid resuscitation. The patient died the 3rd hospital day. Death was ascribed to E. coli meningitis and septicemia, possible urinary source, in the setting of nephrolithiasis and community acquired pneumonia. A diagnostic test returned the same day.

14. Strongyloides hyperinfection syndrome

15. Strongyloides stercoralis • Endemic in many tropical and subtropical countries • Common cause of morbidity and mortality worldwide • Incubation period as long as 60 years • Mild, intermittent eosinophilia may be the only clue to presence, and stool O&P has poor sensitivity • Steroids can cause dissemination and death

16. Maltreatment of Strongyloides infection: case series and worldwide Physicians in Training Survey • Survey of 363 resident physicians in 15 training programs worldwide • Presented with a similar case to that just described • 9% of US trainees and 56% of international trainees recognized the need to screen for parasites • 41% of US trainees were unable to choose any parasite causing pulmonary symptoms • (Our follow up survey 4 years later shows improvement in knowledge and clinician decisions!) Amer J Med (2007) 120,545-551 Boulware, DR, Stauffer WM, et al

17. This case study offers several reflections…. • Diseases travel! • Experts exist worldwide • Lack of knowledge of global mobile populations and their diseases increases personal morbidity and mortality • Healthcare systems could save money if providers were prepared to care for globally mobile populations • Diseases with long latency periods can be particularly devastating (certain parasites, TB, hepatitis B among many examples)

18. This case study offers several reflections…. • The paradigm that in a mobile world, everyone is at risk of diseases from global sources is a relatively new one (several hundred years ) • Our medical education system has not adapted quickly enough or adequately to this new reality

19. Example of a “usual case” at the Center for International Health

20. “International health education” in modern times • Began with the mid 1800’s cholera pandemic • 1851 - First International Sanitary Conference • 1902 Pan American Sanitary Bureau (now PAHO) (a model for transnational information sharing and health promotion) • 1948 - WHO is created out of UN’s desire to have a single global entity charged with fostering collaboration and cooperation • 1948 first Student International Clinical Conference held in Europe – now the Intn’l Federation of Medical Students Associations (IFMSA) Developing Global Health Curricula A Guidebook for US Medical Schools A collaboration of AMSA, GHEC, IFMSA-USA AND R4WH March, 2006

21. Global health medical education in modern times • 1978 - AMA Office of International Medicine • 1991 - International Health Medical Education Consortium (Now called GHEC) • 1997 - AMSA Global Health Action Committee • 1998 - US chapter of IFMSA

22. Medical student education in global health • Didactic lectures and seminars • International electives • International health tracks in medical schools • Attending meetings with global health focus • Collaborating with international researchers • Participating in global health organizations • Mentoring by faculty active in global health • Service learning projects • Complementary degree programs (MPH, Masters in international health policy or development, etc)

23. Graduate medical education in global health • Global health “tracks” in many residency programs within the last 10 years – IM, Pediatrics, Family Medicine, Emergency Medicine, Psychiatry, Surgery • Didactic lectures/seminars • International clinical and research electives • Faculty global health mentors • Local service learning opportunities to work with learn from and about underserved/immigrant populations

24. Practicing physician educationin global health • US-based, and international clinical work/research with globally mobile populations • Diploma in Tropical Medicine courses (17 worldwide) • ASTMH/ ISTM/ICEID/IDSA annual meetings • Statewide refugee health conferences (Canada’s first national refugee health conference – Toronto Nov 2009; statewide conferences in many US states) • Internal trainings and programs developed by healthcare organizations • Cross cultural health consulting firms/website resources • Cross cultural health CME courses/conferences (DiversityRx, etc)

25. Conclusion:An explosion of opportunities in global health medical education has occurred within the last decade • Often driven by the desires of students, resident physicians and practicing providers motivated by altruism and curiosity about other cultures and diseases • Fueled by international travel, movements of globally mobile populations, and the Internet

26. So why the need for a Minnesota Consortium on Health and Mobility? • Tremendous duplication of effort occurs • Medical education programs could be strengthened through greater collaboration • Global health core competencies could be addressed across the continuum of undergraduate, graduate and practicing physician educational programs • The same needs exist across the US, Canada and elsewhere; a Minnesota consortium could be leveraged/scaled to address national/international medical education needs • Funders receive similar requests from multiple organizations in Minnesota and nationally

27. So why the need for a Minnesota Consortium on Health and Mobility? • There is a disconnect between education and implementing best practices in global health clinical care and research (translation: outcomes are worse for globally mobile populations) • Do educational programs make a difference in actual patient outcomes? More research is needed!

28. Some examples of educational consortia Global Health Education Consortium • A consortium of faculty and health care educators dedicated to global health education in health professions schools and residency programs. • 1991 -founded as the International Medical Health Education Consortium, • 2005 - changed its name to Global Health Education Consortium, reflecting the consortium's move to include other health professions besides medicine and a preference for the more inclusive term of 'global' over the traditional one of 'international.' • Members in > 70 health profession schools and training programs in the United States, Canada, Central America and the Caribbean.

29. Some examples of educational consortia Global Health Education Consortium Mission:     GHEC is a non-profit organization committed to improving the health and human rights of underserved populations worldwide and the ability of the global workforce to meet their needs through improved education and training.

30. Some examples of educational consortia Consortium of Universities for Global Health • Formed in 2009 to take advantage of a groundswell of interest in order to achieve life-saving breakthroughs – through research, policy, education and service delivery • Based on the idea that “universities banding together on global health can learn from each other” • Mission: “reducing health disparities from Atlanta to Zanzibar”, and to do this it will: • Build collaborations and promote exchange of knowledge and experience among interdisciplinary university global health programs working across education, research and service. www.cugh.org

31. Some examples of educational consortia Consortium of Universities for Global Health Idea conceived by former Fogarty Director Dr Gerald Keusch 2009 -First organizing meeting among 20 members at UCSF. 58 members now; four criteria for membership: • A well-established global health program • An interdisciplinary program nearly always involving more than one school (medicine, nursing, public health, veterinary medicine and law schools, etc) • Activities encompassing education and training, research and service • A well-established and functioning international partnership www.cugh.org

32. CUGH first priorities: • Defining what is meant by global health education in terms of curricula and competencies • Collaborating among members in research, training and service • Developing a common "platform" for members to facilitate their work overseas • Developing policy and advocacy in support of global health • Creating international partnerships for human and institutional capacity building "I am hopeful that the Consortium will ensure that we catch the crest of the wave of excitement and idealism in our students and faculty to make universities a transforming force in global health” Dr. Haile T. Debas, UCSF Chairman of the founding board of directors

33. Rep. Betty McCollum, D-Minn., greets Duke University’s Dr. Michael Mersonat a Capitol Hill briefing she hosted as co-chair of the Congressional Global Health Caucus. Also pictured are Boston University’s Dr. Gerald Keuschand Dr. Donald Thea.

34. Some examples of educational consortia DiversityRx | Your Voice Peer Learning Networks Peer Learning Networks are groups of 50-100 people who explore a specific topic over 6 months on a private listserv. Our new topics will be on: • Cultural Competence Training: Selection, implementation, and integration of cultural competence training for health care organization staff. • Communicating with Diverse Populations: How to use translated materials, health literacy techniques and other media to address patient language barriers. Communities of Practice Communities of Practice are 12-15 people who learn, exchange information, and provide support to each other on monthly phone calls and a listserv related to a specific topic. Our new CoPs will focus on: • Community Health Workers, Patient Navigators and Cultural Mediators: Training and using patient support specialists to address cultural and linguistic issues and improve access to health services for diverse populations. • Improving Mental Health Services for Minority, Immigrant and Refugee Populations www.diversityRxconference.org/YourVoice December, 2009

35. Some examples of global healtheducational resources Library of Alexandria Supercourse of Science • Launched Jan,2009, at the Bibliotheca Alexandrina in Egypt • Consortium of: the Library of Alexandria, University of Pittsburgh, Google, and the University of Michigan.  • Initial foci of powerpoint lectures to be made available freely through the Internet for teaching purposes: Global Health, Agriculture, Environmental Science, and Engineering.  • Supercourse is a repository of lectures on global health and prevention designed to improve the teaching of prevention. Supercourse has a network of over 65,000 scientists in 174 countries who are sharing for free a library of 4291 lectures in 31 languages. • Example: The Supercourse of Epidemiology, has 3557 lectures, 58,000 teacher/professor users, and an estimated 1 million students reached in 175 countries. • A global initiative, with financial support from the Swiss Development Corporation.  http://www.pitt.edu/~super1/ Website accessed 2/19/2010

36. Minnesota examples of global health educational resources MDH Refugee Health Lending Library Immunization Action Coalition The Exchange Translated materials for the VFR traveler: www.tropical.umn.edu

37. MDH Refugee Health Lending Library (funded by MDH) Immunization Action Coalition (funded by the CDC) The Exchange (funded by it’s member organizations) Translated materials for the VFR traveler: www.tropical.umn.edu (funded by HealthPartners Regions Hospital Foundation

38. What would make this consortium uniquely useful? • Sharing resources and expertise • Statewide clearing house for global health education resources – cases, etc. • Evidence basis for medical education in global health – research on effective global health education models • Minnesota focus for funders • National resource?

39. integration among disciplines and between clinical and scientific foundations increased active, experiential learning enhanced clinical skills development and experiences with patients in years 1 and 2 regular feedback to students for ongoing learning and improvement competency-based approach to student assessment with mapping of the curriculum to each of the competencies Letter from Dean Frank Cerra, The new medical school curriculum at the University, Feb 2010

40. Next steps/timetable

41. Next steps/timetable • The next 2 meetings we will focus on core competencies in global health • You will be sent reading materials • A request : Please send links to helpful materials on global health core competencies of which you are aware; we will compile them • We will contact you with details regarding the health education DVD pilot project and ascertain your interest/capacity to participate in a work group • Please send us suggestions for other members to invite to join us – who are we missing?

42. Consortium website • We are creating a consortium website for your convenience. Please watch for an email with a link. • Selected readings • Links to website resources • Consortium deliberations • Final recommendations and report

43. Thank you and… Take a microbe - you help them travel!