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

1. 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

2. Objectives • Importance of global health work • Ethical challenges & principles for short-term trips • CHIMPS as a model • Challenges • Resources

3. 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 world’s spending on health, yet it ranks 27th in life expectancy2 2Bezruchka, Sickness and Wealth. 2004 1Staton, Pediatric annals. 2004

4. Causes of under 5 child mortality, worldwide WHO, 2004

5. Child health in the U.S. • Only 3% of the world’s 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

6. 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”

7. 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

8. 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

9. 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.

10. 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.

11. 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

12. International Emergency Medicine

13. 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

14. Principles of an ethical international trip • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

15. What is CHIMPS? • Children’s 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

16. 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/

17. Principles of an ethical trip • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

18. Review Organization’s Mission • Defines core purpose and group’s collective beliefs • Religiously affiliated? • Government involvement? • Address public health needs of community?

19. CHIMPS’ Mission “To ethically address underlying health issues and to provide sustainable public health interventions and medical assistance for underserved communities in developing countries.”

20. Principles of an ethical trip • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

21. 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/

22. Principles of an ethical trip • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

23. Educating ourselves • Sociopolitical context • The community • Medical Spanish • Local medical problems • Effective interventions

24. Where do we go? Los Abelines

25. The Official Summary of The State of the World's Children, UNICEF, 2004.

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

27. Educating ourselves • Learn local language • Understand local medical problems • Dental health • Intestinal parasites • Nutrition

28. 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 2O’Lorcain, Parasitology. 2000 3Yip, J Nutr. 2002 1Marinho, Cochrane Database. 2005

29. Educating others • The community • Health talks (“charlas”) • Our peers • Publications, speaking opportunities, etc.

30. Principles of an ethical trip • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

31. Service: “Doing work that the community needs and wants” • Clinical medical care • Linking the community with the local physician • Public health interventions

32. 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

33. Bienvenidos a la clinica!

34. Gathering health statistics

35. Things we can treat… Tooth abscess Impetigo Scabies

36. The difficult cases we can’t…

37. 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

38. Applying fluoride varnish Now you try it

39. Best brusher competition…

40. “Teaching the teacher”

41. Building confidence

42. Charlas in action

43. Principles of an ethical trip • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

44. Teamwork • Our medical education model:

45. The Original Dream Team, CHIMPS 2003 CHIMPS 2004

46. CHIMPS 2005 CHIMPS 2006

47. Principles of an ethical trip: • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

48. Sustainability = building capacity • Working in a single location • “Teaching the Teachers” • Augmenting existing systems of care • Respecting cultural norms

49. Principles of an ethical trip: • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

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