Category Archives: Cultural Humility

Cultural competency or a cultural awareness and sensitivity

Refugees and the Desire for Education

by Caity Jackson
Director of European Engagement

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Unusually hot weather welcomed me to the town where The Beatles famously made their debut. Coincidentally, the theme of the conference was ‘Imagine’, with a strong emphasis of thinking outside of the box and engaging everyone’s imaginative side in relation to European and international education.

But ‘imagining international education’ had a more serious tone this year, with the presence of sessions focusing on refugee education and how to increase inclusivity in all aspects of the recruitment, delivery, and evaluation of the educational process. How are we making international education possible for all?

This year, the EAIE conference held a track focusing on refugee education, in an attempt to address and respond to the refugee crisis in Europe. These 13 events focused on fair admission, recognition of international educational attainments, and how Germany is responding to the influx of refugees through intercultural certifications and integration programs.

Not only being represented through sessions and posters, refugee education wove itself into the opening and closing plenary of the entire conference. Kilian Kleinschmidt began his keynote address with harrowing figures: 1.2 million people have been displaced from their homes over the last year, with the total budget available for all aid, including refugees, natural disaster assistance, etc, worldwide, adding up to approximately US$20 billion. “Compare that to the money spent on real estate development and you understand why aid is the wrong concept. Aid is an arrogant concept of charity”, Killian asserted.

Photo by: Russell Watkins/Department for International Development

Photo by: Russell Watkins/Department for International Development

‘Imagining’ again that education for all is within our grasps, sessions focused on overcoming the barriers international education recruiters/marketers, administrators, and alumni coordinators face when it comes to a mobile population. How can we value our prospective and current students and erase the dollar sign universities associate them with? How can we increase diversity on campus while ensuring students have all the services they need to succeed at their fingertips? In only a few days, participants left with imaginative answers, if not even more questions to guide their work.

Diversity has always been a focus of the work that CFHI has engaged in. We imagine a world in which there are no barriers to the enriching experience cross-cultural learning can give. Our many scholarships aim to address these barriers and we are proud of the breadth of diversity in our scholarship applicants and successful candidates and we are honoured to walk side by side with our partner organizations.

Wrapping up this event that saw over 5000 professionals from over 90 countries gather in the spirit of increased global cooperation, Melissa Fleming of the United Nations High Commissioner for Refugees (UNHCR) told stories of those that our work has not reached. These stories from some of the most dire situations of the world, where the hunger to learn is beyond any of our comprehensions, was the inspirational closing we needed. Melissa began her talk with an account of her experience taking her own daughter through the steps of studying in France. She then told us about Esther, a young refugee whose main aspiration is to become a neurosurgeon. The contrast, in terms of opportunities for these two equally young and motivated women, is evident. If education offers life opportunities, why are we failing to provide this to those who need it most? As Melissa put it: “my daughter’s future is in her hands, Esther’s is in ours.”

Travel vs. Transformation: Career Impacts

Travel and Cultural Intelligence

“Where are you from?” is often the hardest question for me to answer. Do I give the short answer, the long answer, or settle for “it’s complicated” like a provocative Facebook relationship status? Yet that dilemma is a small price to pay for all I’ve gained through experiences living and traveling around the world.

A study from the journal of Social Psychological & Personality Science found that those who engage in multicultural and international environments are more likely to be offered jobs. At surface value, this comes as no surprise; in any arena these days—school, job, socially, or otherwise—it is beneficial to set yourself apart, and “multicultural experiences,” are a great way to do so. But simply accumulating stamps in your passport is not enough. In an article on the study, David Livermore writes “If business travelers spend their time at international hotels and offices; and if study abroad students spend their free time on Skype and Facebook, travel may have little positive benefit for improving CQ (cultural intelligence) and career opportunities.”  Travel creates a possibility for transformation through exposure to new cultures and ways of life. But it is easy to pass up that opportunity and flock toward familiarity instead, to head to a Starbucks in a foreign country or find solace from strange surroundings amongst fellow visitors.

The Transformation: How You Engage

Transformative travel requires openness. As more and more and more people seek programmed multicultural experiences— study abroad, volunteering, or simply sightseeing—it is important to evaluate your own goals and the goals of the organization. Responsible international travel necessitates embracing the discomfort and challenges of unfamiliarity, and also willingness to let go of your own authority: to follow the leadership of the locals and see the positive aspects of a community rather than perceived negatives.  To me, the most striking overseas experiences have involved connecting with people through common humanness despite apparent differences. These experiences, not traveling itself, are transformative.CFHIMapWhite

I was drawn to work with Child Family Health International (CFHI) because their global health programs promote an immersive experience through community-based projects and perspectives. Interning here and learning about CFHI programs over the past month has made me reflect on my own international experiences. I was born in the U.S. but since age nine I have lived abroad in different countries with my family. Though I have spent much of my life overseas, some who go abroad for shorter periods of time have had more intensive and challenging cultural experiences than mine. It can be easy to entrench yourself in an expat community and become complacent about pushing beyond that.

The study suggests benefits of international travel for your career; I don’t see my experiences overseas as having made me marketable, though I can’t complain if that is a byproduct. Rather, I see travel as the defining aspect of my life that has provided more unique challenges and rewards than anything else. CFHI’s motto encourages students to “Let the world change you,” instead of trying to change the world. It has and will continue to change me throughout my life. And maybe even get me some jobs too.

 

Special thanks to our guest blogger and CFHI Summer Intern Karoline Walter for authoring this post.

Internationalizing Medical Education: Shaping Healthcare Providers for Global Health

Internationalized Medical Education: How do we develop competency-based education and realize its full potential?  UN-recognized NGO Child Family Health International (CFHI) has been running global health education programs for over 20 years.  We have seen a lot along the way since our beginnings in a small garage in the San Francisco Bay Area.

Global Health and Study Abroad See Upward Trends

CFHI Uganda Program Photo Woman

Fast forward to 2014.  Global health has become a buzzword, conjuring up images of Bill and Melinda Gates projects and Partners in Health initiatives.  Once a field that rallied for press, global health is receiving increasing limelight.  Take a look on the Kaiser Family Foundation webinar on U.S. spending towards global health initiatives or the entire Center for Global Development event devoted to discussing Best Buys in Global Health. Global health teaching in undergrad and medical curricula is also increasing and the 2013 Open Doors Report on International Educational Exchange, states study abroad by U.S. based students is steadily increasing and is at an all time high.   The Association of American Medical Colleges data demonstrates that 35% of US medical students participate in international experiences.  Spurred by increased participation, global health education is evolving from a phenomenon of one-off volunteer experiences to a field of educational theory and practice, shaping the world’s next generation of healthcare providers with skills demanded by an increasingly inter-connected world.

Looking at Competencies in Medical Education & How Students Engage

A study in the journal Academic Medicine shows the structure of global health programs, the degree to which they are imbedded in local health care systems, and having a capacity-building agenda, affects what students learn.  In an era where competency-based education is dominating pedagogy in medical education, we must leverage the richness of global health experiences to meet accreditation standards and competency-based outcomes.  Like studies have shown and CFHI’s 7,000 alumni can attest, global health exposure and international experiences make for better practitioners and global citizens.  CFHI’s approach leverages asset-based engagement and encourages students to “Let the World Change YOU.” stethescopeglobe

As we strive to meet demand and look at the nuances of programming, we must continue to examine students’ international experiences. This month thousands of international educators will gather at the NAFSA conference and discuss these topics at the Colloquium on Internationalizing Education for the Health Professions.  Here and on our own we must consider key questions—what competencies does a globalized health practitioner need?  What competencies are nurtured during global health programs? How do we wed international global health and what is taking place in our own back yards?  Just as important, not all global health experiences are created equal.  As educators and leaders in the field, we must advocate for socially responsible and ethically sound approaches to placing students in health settings abroad.

Truth in the Spoof: Medical Voluntourism in The Onion

Truth in the Spoof: An expose of voluntourism in The Onion.

By: Aditi Joshi, MD

Newsflash!  This week’s headlines report a new humanitarian organization ‘Doctors Without Licenses’ will start providing substandard care by putting together a group of “decertified physicians, pre-medical undergraduates, and ‘people just interested in the human body’.” The organization states it will be sending their staff to conflict zones and underserved areas to incorrectly provide medical care.

Image from The Onion satirical article

This news was reported in The Onion, a satirical weekly publication, so it is, of course, facetious. The sad truth is that it refers to a very real phenomenon.

Voluntourism and Medical Voluntourism – Repercussions

Searching ‘voluntourism’ on Google, one finds a number of hits for organizations that set up volunteer opportunities for well-meaning individuals to work in underserved communities. Medical voluntourism refers to doing medical care within these communities; these volunteers can be physicians, nurses, residents, medical students and a growing number of organizations offer hands-on opportunities for pre-medical students, as well. More and more research as well as anecdotal reports state that these short term volunteer trips do more harm than good to the local community.  (If you’re interested in a great contrast between voluntourism and global health—this article is a must read. The volunteers may be providing direct patient care, giving medications, and doing procedures. In cases where the volunteer has no formal training, and would not be allowed to do the same in their home countries, this type of care is unethical whether or not the results are disastrous.  Even for those who are trained and skilled, the lack of knowledge of local infrastructure, drug formularies, culture, language and historical frameworks can actually lead ‘good’ actions to having negative consequences.

Solutions and Social Responsibility

Proposed solutions vary as the scope of the problem is large and not fully realized. However, organizations such as Child Family Health International – CFHI, try to decrease harm by giving students the opportunity to immerse within the culture, focus on broad global health competencies, observe native health care providers who are dedicated to their communities long-term health. This prevents the student from being a short-term ‘band-aid’ health worker or trying to get patient care experience that they are not licensed to undertake. The students are able to understand health concerns in other countries while minimizing possible harmful outcomes.

Voluntourism is most likely here to stay, however the importance of finding ways to reduce harm while giving the local community the help it requires is an ongoing challenge.

 

Thanks to our guest blogger, Aditi Joshi MD, ER Physician and Former President IFMSA-USA for authoring this post.

CFHI Salutes Medical Director Dr. Raj on World Social Justice Day

February 20th is World Social Justice Day. We would like to take this day to highlight one of our partners who has been working to achieve social justice. Dr. Rajagopal has been helping to reform the Hospice and Palliative Care laws in India through his organization, Pallium India.Through both personal visits to patients, and by building a strong system of doctors across the nation, Dr. Rajagopal has highly improved the state of Palliative and Hospice Care in India. Access to Morphine and Pain Killers is an enormous problem in India because of previous problems with morphine addictions. India has the highest amount of victims for mouth cancer, and it is estimated that less than 3% of cancer patients get proper pain relief. (1)

Dr. Raj conducting a home visit, Trivandrum Southern India

Dr. Raj conducting a home visit, Trivandrum Southern India

Fortunately, laws in India have been changed. Now, a policy has been set so that in Kerala, doctors with at least 6 weeks of training, such as Dr. Rajagopal, can prescribe morphine for palliative care. (2) The rule was introduced in June 1998 in Trivandrum, the capital city of the state of Kerala. Since then, the central government has recommended this new rule to all the states in India. The idea of easier access to morphine and other pain relieving drugs was initially recommended by organizations and committees such as WHO Collaborating Center for Policy and Communications in Cancer Care (Wisconsin, USA). The Center is currently attempting to simplify complicated state narcotic regulations to further improve the availability of opioid analgesics.

Through his organization, Pallium India, Dr. Rajagopal strives to provide Palliative and Hospice care to those that need it. Not only does Pallium India provide medical care to patients, but the organization also provides resources such as food and sewing machines to the patient’s family to help them get back on their feet. CFHI has partnered with Dr. Rajagopal to launch the Palliative Care In Southern India Program in Trivandrum, India that centers around Hospice and Palliative care. The CFHI participants involved in the program are given the opportunity to visit the patients and experience first hand how patients are treated and managed. Pallium India and CFHI have worked together to reform India’s Hospice and Palliative Care system.

(1), (2) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3573467/

 

-Special thanks to guest bloggers Alexandria Tso and Nayanika Kapoor for contributing this article.

CFHI vs. Brigades: Defining “Helping” in Healthcare Abroad

A Doctor Walks Into a Community..

For healthcare professionals or those on that path, it’s tempting to drop into a community abroad and start treating patients.  The stark realities of poverty, lack of resources, and unaddressed illness provides an often disturbing (and therefore motivational) contrast to our Western frame of reference.  We are often shocked and saddened.  As a consequence, we want to help.

An important question arises however, when we are students or even when we are credentialed professionals visiting a faraway community, what’s the best way to help?

Two Approaches to Global Health aamcacademicmed

An article profiling Child Family Health International – CFHI’s Global Health Education Programs in the current online edition of the Association of American Medical Colleges’ journal Academic Medicine contrasts two interpretations of ‘helping.’  The article contrasts CFHI’s program structure to that of brigades.  Brigades are short-term (often lasting one or two weeks) international activities that set-up clinics in parallel to or completely outside of existing health systems.  These temporary establishments are meant to see many patients in a short period of time. Commonly, medications, often drug samples, are brought down from the home country of volunteers and dolled out to patients.

The students writing the article draw an important contrast between the two definitions of ‘helping’ represented by CFHI Programs and brigades.  Brigades aim to ‘help’ by directly treating patients using Western physicians and students.  But they do so often at the expense of follow-up and continuity of care.  Brigades define ‘help’ in a very immediate sense.  Contrastingly, CFHI defines helping as empowering local communities and using Western funds to develop and elevate the stature of the native health care workforce.  CFHI positions local physicians, nurses, and community members as local experts, in a unique role to teach outsiders about their approach and insight. CFHI  believes they are the sustainable solutions to global health challenges.

Humility and Knowledge Key

CFHI Student with Local Doctor, India

CFHI Student with Local Doctor, India

CFHI’s definition of helping is perhaps more humble, believing we need to first respect and attempt to understand the complexities that underlie global health challenges, rather than trying to address these challenges with immediate auxiliary patient care.  This admiration of local health care providers and the goal of first comprehending the complexities of global health disparities is fundamental to shaping the collaborative global health leaders of the future.  Before we try to change a reality, we must begin to understand it.  This understanding is afforded by CFHI’s Global Health Education Programs.

Social Justice: Embracing Global Health Complexities

Internationalizing Medical & Health Education

At the recent NAFSA Conference for international educators, the Colloquium on Internationalizing Medical Schools proved to be a forum marked by many thoughtful remarks, especially those of the opening speaker Edwin Trevethan, MD MPH.  Yet nothing struck me as much as the name of the school he heads–  Dr. Trevethan is dean of the St. Louis University College for Public Health & Social Justice.  The social justice part piqued my interest.  Social Justice is a term that did not receive enough exposure during my undergraduate and medical education, despite dedicated studies about global health, underserved care, and health equity. jessicanlauren nafsa 2013

Importance of Social Justice in Health Evolving

Why hasn’t this term gotten the play it deserves?  What does it mean anyways?  One of my favorite definitions of Social Justice is a “historically deep and geographically broad” understanding of gross inequities, power imbalances, and underlying causes of ill health.  Dr. Josh Freeman, the creator of the blog ‘Medicine & Social Justice’ offers further insight into definitions of justice, social justice, and how they relate to health and health care.  Social Justice has also been studied as one of the key ethical principles for students wanting to be involved in Global Health.  Increasingly there has been discussion on whether social justice should be a factor when selecting students for admission into medical school.

I think the reason Social Justice has not always made it into our medical and educational syntax is that it encompasses the utmost complexity.  Particularly in medicine we like things that we can boil down to cause and effect, test while controlling for variables, and fix with evidence-based antidotes.  Social justice doesn’t allow us to be logical and create such neat solutions.  Social justice demands we consider a host of influences on health, wellness, and disease.  It requires that we humble ourselves.  It requires we admit that problems causing health inequities worldwide defy the scope of one solitary discipline, or the involvement of just one prestigious university.

I want to commend St. Louis University and Dr. Trevethan’s leadership for their insight in going so far as to include social justice in name of their school of public health.  They, alongside other leaders such as CFHI partner association American Medical Student Association, demonstrate the fundamental ability to embrace the complexity of global health, and not unlike CFHI persevere with programming and partnerships that give social justice its due attention–both as a goal and as a lens through which to understand health.

At the annual NAFSA: Association of International Educators Conference CFHI was represented along with over 8,000 professionals who come together in late May each year to network and learn about today’s issues related to the fields of study and interning abroad.

Student Essays Reflect Realities and Impact of Global Health

Student Essay Contest Winners with CFHI Executive Director Jessica Evert, MD (far left)

Student Essay Contest Winners with CFHI Executive Director Jessica Evert, MD (far left)

At CUGH’s Annual Meeting last week in Washington, DC educators and students from over 60 countries met to discuss the global health landscape.  Perhaps one of the most powerful and emotional sessions was one that captured power of reflection in global Continue reading

International Women’s Day- A Story From CFHI India

alwar2Evaleen Jones, MD is the founder of Child Family Health International (CFHI) and Clinical Faculty at the Stanford University School of Medicine.  Today, on International Women’s Day we feature an experience from her recent visit to CFHI partner sites in India, and a story from a woman she met while there.  Her story  carries the message of community empowerment that CFHI embodies.

January 31.  Today we visited Continue reading

CFHI Featured at AAFP Global Health Workshop

Child Family Health International’s  Quito, Ecuador Medical Director Dra. Susana Alvear and Global Medical Director Dr. Jessica Evert were featured in the closing keynote address of the 9th Annual AAFP Global Health Workshop.  Nearly 300 attendees from 25 countries attended to share ideas, evidence, and inspiration on topics ranging from global health education at US institutions to the proliferation of family medicine around the world to the ethical challenges of global engagements.

Drs. Alvear and Evert presented on the realization of ethical aspirations- breaking down ethical concepts into practical topics and tangible actions.  The presentation was warmly received.  Dr. Dan Ostergaard,  AAFP’s Vice President for Health of the Public and Interprofessional Activities emphasized the application of CFHI’s motto “Let the World Change You” for all trainees, faculty, and physicians active in global health.  He also emphasized the concept drilled home by Drs. Alvear and Evert that we should really speak of “Toward Equity” rather than “Equity” itself given the gross disparities around the world.  Drs. Evert and Alvear emphasized the ability of institutions and individuals from developed countries to highlight the value of assets in developing country contexts—for example, richness of culture, strong traditional medicine practices, resourcefulness, rather than emphasizing the disparities of financial resources in order to ‘level the playing field,’ a concept originating from CFHI’s former Executive Director, Steve Schmidbauer.

Great respect and admiration were expressed for CFHI’s leadership, program structure, and partnership model.

New MCAT Means Greater Need for Global Health Exposure

The New MCAT – Shaping Future Physicians for the Better

For pre-medical students their life choices are often defined by the MCAT—the often-dreaded U. S. medical school entrance exam that determines whether their professional dreams are dashed or realized.  Rarely do we consider that what we test and emphasize on such exams determines what is prioritized in undergraduate education and consequently Continue reading

Students Asking Difficult Questions on Global Health Engagement and Development

During the Western Regional International Health Conference I had the privilege of lunching with a group of inspirational and innovative undergraduate students from the University of Washington and University of British Columbia.  At University of Washington students have created the Critical Development Forum (CDF),  a think-tank creating Continue reading

World AIDS Day 2011

On this 30th anniversary, World AIDS Day gives us a time to pause and take in the enormity of this disease that has ravaged so much of humanity.  There will be much written today about how we are turning a corner and that the epidemic is showing signs of coming to an end.  It is important to celebrate and salute the great accomplishments in the fight against AIDS but it is also important to note that we are a long way from taking a victory lap.  We do need to build momentum in the fight, so the accolades are helpful as long as they help generate enough buzz and enough energy to follow through by implementing and building on the advancements that have been made.

Unfair

The latest numbers show that there are about 34 Million people with HIV world-wide.  At CFHI, because of our international partnerships, we are acutely aware that among all the world’s AIDS statistics it is particulary sobering to note that 60% of all cases are in Southern Africa and that South Africa has the horrible distinction of being the country with the most cases.  Also it is important to note that statistics shoe that among all Asian countries, India has the most cases.  When we look at global health disparities in general, we see how unfair the realities of burden of disease and access to healthcare are but in the context o this particular disease, it is somehow even more shocking. Try to take some time this World AIDS Day to educate yourself.  The World Health organization has a wealth of information, you can start at this link.

One of the great privileges for me as part of CFHI, is the opportunity I get to visit doctors, nursers, and other healthcare workers in the field.  As you really cannot even begin to imagine, communities where the prelevance of HIV/AIDS is very high, are impacted in a variety of ways.  On World AIDS Day, I think back on the doctors and nurses in hospitals that are inundated with patients due to the epidemic yet they still push on, they still show up even when success is not a common part of their day.   Finding local health professionals who are dedicated to their own underserved communities and trying to support them in their work is at the heart of what we do.  We see them in hospital wards that are overflowing, we see them on strenuous trips to rural areas to test, educate, and treat -thus making treatment and  healthcare accessible to  more of the population.  We see them in hospitals where the staff room has become a small ward or infection control area thus leaving them spending long hours working with no place to go for a break.  We see them in clinics working tirelessly as as line of patients stretches out the door and down the street, more than a city block.  We see them morn the loss not only of patients but of so many of their colleagues, and yet they continue.  We see them in these situations every day, and we see them more dedicated and more earnest in their efforts each day.  These are real heroes in this global fight and we salute you on this World AIDS Day and we pledge our continued efforts to help support and champion your work.

On this World AIDS day, 2011, it is particularly wonderful to note that a new film is debuting in South Africa.  Inside Story: the Science of HIV/AIDS will be premiering across South Africa.  A wonderful attempt to target the exact population that the epidemic is targeting –young people.  Using live action, computer animation and, yes, football (soccer), the goal is to educate through entertainment.  Actors from different African countries are participating in hopes that the film will gain audiences across Africa.  In addition to a love story and a sports story, the film shows through animation what is happening inside the body as HIV and AIDS run their course.  The effort deserves a two thumbs up even though we have yet to actually see the whole film.  We hope that this film can be more effective than any drug at combating the disease.

CFHI’s Model for Global Health Electives Included in Oxford University Press Publication

Oxford Handbook on Neuroethics

Oxford Handbook on Neuroethics

“Global Health Ethics is once again in the forefront of discussion with the recently published Oxford Handbook of Neuroethics chapter emphasizing the relevance of biomedical, clinical and public health ethics within the global medical and academic community.  Child Family Health International’s (CFHI) Evaleen Jones M.D., Jessica Evert M.D., Scott Loeliger M.D., and Steven Schmidbauer co-authored the chapter on the importance of establishing and sustaining an ethical framework for educational global health programs.

With growing interest in Global Health Electives among the medical and academic community, there are genuine concerns regarding equity, justice, and sustainability within underserved communities.  CFHI’s chapter discusses global citizenship via a socially responsible framework to create positive global health educational experiences for students and host communities, connecting students with local health professionals and through direct investments in local community based projects.  ”

So reads the beginning of the Press Release for CFHI issued today.  Needless to say, we are all very proud and very happy to have this recognition especially from such a noted publisher as Oxford University Press.  The portion that CFHI contributed to this chapter on Global Health Ethics is an attempt to describe our model of working in underserved communities by identifying local experts and building on the inherent strengths of the communities.  We have seen over and over again low-resource settings where amazing things are being accomplished every day in patient care due to extremely dedicated local professionals.  We see their deep commitment to serving the people and we join together with the local health professionals to design Global Heath Education Programs that are open to international students and trainees.  You can read our submission here but I want to take this opportunity to thank all our international partners who have chosen to work with us to develop this model and make it successful for the last 20 years.  No partnership is one-sided and we are deeply indebted to all the local doctors and nurses, hospital and clinic staff, local coordinators, host families, language teachers, drivers and many others who make our international programs function so well, even in some very challenging circumstances.  Our hats are off to all members of the CFHI global family –you all share in this recognition!

Read the full CFHI Press Relase and Chapter.

Empowerment Means Having a Voice

Voices of empowerment from women in rural Northern India

About an hour outside of the north Indian city of Dehradun, the terrain starts to change as you begin to enter the foothills of the Himalayas.  Paved streets give way to winding dirt roads, some seemingly carved into the incline of the mountain like the etches of a screw and only wide enough for one vehicle.  Luckily almost no one in this area has a car, so we are usually sharing the road only with the monkeys and the goats.  On this particular trip, the monsoons have not yet released India from their grip and our vehicle struggles on the loose dirt and gravel as the torrents of rain pour down.  Oddly enough, here, about as far away from an urban setting as you can get, I’m reminded of a car wash because the sheets of rain are hitting the car so hard that you can feel their force on the hood of the vehicle like the power washes you can get back home.

CFHI Logo SmallLuckily, as we reach the village of Patti, the torrents subside and we are able to disembark without getting too wet.  CFHI has supported the operation of a clinic in this area since the late 1990s –it is the base of the CFHI Rural Himalayan Global Health Immersion Program.  In the last seven years, we have trained women elected from the surrounding villages as health promoters.  Previous to these efforts, there was no organized healthcare happening in this area.  Today is a meeting of the health promoters, some having walked as many as five hours for the event (a fact that always humbles me greatly).  An initial three year training effort took women with little or no formal education and taught them the basic skills of health promotion.  Many of them come from a long line of traditional birth attendants, so they already had some experience in the area of health.  After the initial training, they have been able to monitor women throughout their entire pregnancy.  Additionally, they instruct their communities on many topics: sanitation, nutrition, immunizations, hygiene, and family planning, to name a few.

As the rain began to intensify once again, we huddled around two tables pushed together on a porch, under a metal roof, next to a rice field.  The sound of the rain caused everyone to move in closer and lean in to hear.  My many previous visits over the years have been in more extreme dry heat when we sat spread out in the shade as we

CFHI Health Promoters Meeting in the Village of Patti, Northern India

CFHI Health Promoters Meeting in the Village of Patti, Northern India

talked.  –Of course I need to stop here and say that since I have no capacity in Hindi, the CFHI India Coordinator, Ms. Hema Pandey, was gracious enough to do the translation, and her easy, relaxed, yet professional manner also contributed greatly to the level of the conversation.  Maybe it was this more close huddling, or maybe it was just the product of seven years of meeting them once or twice a year, but for whatever reason, this time the conversation took a more intimate track.  Over the years, our meetings have been about stories of the work the Health Promoters are doing, each in her own village.  I’ve always been moved by their commitment and dedication as the women are all volunteering in this role and, at times, it can occupy a lot of their time and energy.  We always talk about what they need and we try to line up successive training experiences for them.  Today, however, I somehow felt like I could ask them more about themselves.  Now, all these years into their work, I could see in them their own sense of being experienced –that they are really settling into their roles.   It also helped that there was a young 18 year old woman who had joined us for the first time, as she now wants become a Health Promoter.  The older women took her under their collective wing as she found it hard to answer any direct questions –not used to being asked her opinion.  “Don’t worry, you’ll get used to it,” was the message as all the older women laughed.  “We were all once like you,” one of them told her, “not knowing how to speak, not sure what to say … you’ll learn.”  It was also touching to see the older women buoyed in spirit by her interest.  There was more of a general feeling –not only of pride, but also of purpose, and an almost palatable sense of hope for the future in the smiles of the older women, broader than I have ever seen them before.

I asked the women what they liked most about their work.  They answered with the stories of what they have been able to do.  “And for you,” I asked, “what do YOU like about it.”  There was some discussion amongst the group. They said that they like “feeling empowered.”  “What does it mean,” I asked, “to feel empowered?”  “It means that now I can speak,” said one, motioning to the new recruit whose personal growth and self confidence the women will now each personally see to.  “It means I can teach,” said another.  “It means improvement, progress for the whole village,” said another.    This spawned a longer conversation of the feeling of satisfaction they have in seeing the results of their work.  They see women having healthier pregnancies; they see children growing up stronger and healthier.  One of the biggest changes, they report, is that now, even the men of the villages will listen to them in a way that never happened before.  The women told me that the men have come to see the women as possessing knowledge and understanding as a Health Promoter that no one else has.  What was even more remarkable than the statement itself was the body language, the tone of confidence, and the feeling of accomplishment that came through in these statements, none of which required the skills of a translator to be successfully communicated.

A Visit with The Father of Palliative Care in India

Dr. Rajagopal Dispenses  Needed Medicines and a Healthy Dose of Respect.

Pallium India

Pallium India

 

After a meeting with CFHI’s Founder, Dr. Evaleen Jones at Stanford University, Dr. Rajagopal (Dr. Raj),  the Founder of Pallium India agreed to become one of CFHI’s newest partners in India.  CFHI India Coordinator, Ms. Hema Pandey, and I had the privilege of spending three days with him in Trivandrum, Southern India as we work to develop a CFHI Global Health Immersion Program exploring Palliative Care.

As the monsoon season takes its time to come to a close, the beautiful, lush countryside around Trivandrum in Kerala –Southern India is as calming as the Trivandrum, Indiapresence of Dr. Raj to his patients. We were given the great privilege of being allowed to shadow Dr. Raj during a day of home visits to various patients of Pallium India, the nonprofit he founded.

Who is Dr.  Rajagopal

Dr. Raj is responsible for beginning the palliative care movement in India.  He tells me that while the goal of palliative care might be the same in India as it is in England, where the modern hospice movement was started, the implementation is different.  Dr. Raj feels that to simply pick up and transplant palliative care as it has been developed in the West can inadvertently have consequences that cause more suffering –when the main goal of palliative care is to reduce suffering. Dr, Raj is indeed a unique individual; he is both a visionary and a worker in the trenches.  To follow him for a day doing home visits was inspiring.  It was also a primer in how to do this kind of patient care.

Dr. Raj pointed out to me the four domains of patient care that were outlined by Cicely Saunders, the founder of the modern hospice movement.  The four interlocking domains are Physical, Emotional, Social, and Spiritual.  It is certainly a tall order for anyone to provide such comprehensive care, and to do it in low resource settings is even more challenging.

A Day in the Life– Implementing Palliative Care in India

As we drove into some of the poorest communities in Southern India, Dr. Raj and his team, a nurse, a social worker, and a driver went about their routine.  Patient files are reviewed as we travel in the van.  The size of the patient files is notable.  After Dr. Raj read the file a bit, he begins to tell us the context of the family we are about to see.  We get a succinct yet

Ms. Hema and Dr. Raj on home visits Pallium India

Ms. Hema and Dr. Raj on home visits

thorough description of the family composition and history.  The level of detail is impressive and we even had a few questions about the family that Dr. Raj answered from the record.  I asked him when he last saw the family and he said that this was his first visit to them.  There are three other teams conducting home visits and so the family has been seen by the other teams in the past.  It is amazing to see the level of detail that is recorded from the home visit.  From these notes, other services from nutrition, to physical therapy, to social work are provided –all driven initially from the teams’ weekly or fortnightly visits.

As we arrive, Dr. Raj gives warm and respectful greetings.  He makes use of his reading of the chart right away to let the family know that he is up to speed on the situation even though this is his first time seeing them.  Telling and retelling the story can be a help, at times, for a family but to have to do it with every healthcare worker that shows up, can become a burden.

In the home visit, Dr. Raj is totally in his element.  Calm, positive, and respectful, he has a way of making the patient and the family feel that he has all the time in the world to spend with them –they have no idea that he has six more home visits to do.  His careful touch, his undivided attention, his deep listening, his affirming comments are all the epitome of what a home visit should be.  He listens and draws

Dr. Raj conducting a home visit, Trivandrum Southern India

Dr. Raj conducting a home visit, Trivandrum Southern India

out information to help him tweak the treatment plan based on what has happened since the previous home visit.  As he leaves, he has given not only some medicines and ordered some more physical therapy but he has also given the family and the patient dignity, respect, and acknowledgment through his manner, his interactions, and his presence.

And, of course, as we make it back to the van, it’s time for Dr. Raj to write page after page of notes so the follow-up treatments can be done and so the next home visitor can pick up right where he left off.

 

New US Census Data Shows Diversity of US Population Increasing

We are approaching a new highpoint in the prevalence of US residents who were born outside the country.”  This is part of a message on the Director’s Blog of the US Census Bureau website that is aimed at the marketing industry, at advertisers of goods and services, but we at CFHI believe it is also important information for current and future health professionals.

While the Census Bureau is providing this new data, none of the basic trends of an increasingly diverse population for the United States should be a surprise to us.  Forward thinking health professionals and medical educators have seen the indications of these trends for many years.  Health science students (including medical students, nursing students, and public health students) have not waited for courses to be developed by the data that is now beginning to be analyzed, but have taken the initiative to seek out medical electives and rotations that would give them first-hand experience of different cultures and the different ways people view health around the world.

Source: US Census Bureau -Director's Blog

With some 6,000 alumni of CFHI Global Health Immersion Programs to date, we hear over and over again from them how their CFHI experience gave them insight into the role that culture plays in health and healthcare.  Tenny Lee, a 2010 CFHI Mexico alum, reports: “My experience in Mexico has given my medical career a foundation to help underserved communities and break though language and cultural barriers.”  You can read more about her CFHI experience  in her review posted on the website Great Nonprofits.  The ability to competently serve a more widely diverse patient population will clearly become the expectation for health professionals, as we can see from the wealth of information that the US Census Bureau is releasing.

One of the most important data points released so far is that the Hispanic population of the US now exceeds 50 Million, a 43% increase since the last census as reported by CNN.  And it is not just in border states in the south.  The CNN article quotes demographer Jeffrey Passel at the Pew Hispanic Center as saying, “Previously, the Hispanic population was concentrated in eight or nine states; it is now spread throughout the country.”

Medical schools, organizations, and institutions of higher learning have also recognized these trends, and CFHI has been happy to work with many of them to design specific programs.  The Patient Advocacy Program at the Stanford Medical School began a program abroad with CFHI in 2007.  The University of California at Davis has partnered with CHFI for over five years now to offer a Bi-National Health Quarter Abroad program for undergraduates in special arrangement with the Chicana/o Studies Department at UCD.  Both of these programs also make use of CFHI’s built-in Spanish Language and Medical Spanish Instruction.  Students are also living with host families so they are immersed into the culture during the program.  Guided journaling and weekly meetings help students reflect and integrate what they are learning from their daily interactions.  CFHI is also working with others, including Northwestern University, The Student National Medical Association (SNMA), -which you can read more about in an earlier posting–  and the Public Health Institute in association with the Global Health Fellows Program.  CFHI has been able to partner with each group and use our 20 years of experience working at the grassroots level in underserved communities abroad to design programs that meet specific learning objectives that are achieved in real life settings with the help of local health professionals who have the unique expertise of the local healthcare system and the best understanding of the local culture.

Jessica Brown, a 2010 CFHI Ecuador alum, pulls it all together in her reflection about her CFHI experience:

“… [I] learned a wealth of information about health that extended beyond the Reproductive realm.”  Jessica goes on to say, “I learned a lot about Ecuador’s healthcare system by discussing health care access, education, socioeconomic class and ethnic background with my mentors and preceptors. I learned about how religion, education and customary social/cultural schools of thought (i.e. machismo) weigh heavily on Ecuador’s society, and individual minds; I saw how the cultural “way” dictated the population’s attitude towards healthcare, especially in Women’s Reproductive Health.

The moments that caused me to question belief systems in place within myself really stretched me beyond limits I never knew possible.  And it is these reflections upon the state of health care in Quito that can broaden my understanding of client needs, beliefs and culture here in the states.”

The Roots Have Taken Hold –A Follow-up on a Success Story in the Making in South Africa

Ukwanda Logo

Ukwanda Logo

In October of 2009, fresh from a visit to South Africa, I wrote an entry to this Blog called The Roots in Grassroots –Ukwanda Rural Health Program.  I was so impressed with the intentional efforts of the University of Stellenbosch to successfully bring primary health care to Avian Park, an underserved community in the rural areas well north of Cape Town.  CFHI’s work has always intentionally been at the community level so this was the first time that we were helping to fund a project of a university.  On paper, it looked like a serious effort to truly do the relationship building and ground work necessary to successfully establish the first primary healthcare facility for this poor but growing community.  Our contacts on the ground were also very enthusiastic about this initiative and so CFHI chose to help support it.

What I saw in 2009 was an idea beginning to take form.  What had looked so possible on paper, was proving to be a significant challenge to implement.

Avain Park Old Clinic

Avain Park Old Clinic

I saw a very run down set of metal freight containers being used as a makeshift TB clinic.  I saw some initial linkages with the community but everything was still new and tenuous.  CFHI’s commitment was funding that would be used to renovate the freight containers to make them fully functional.  The project was already well beyond its targeted schedule and I could see during my visit that the freight containers were not in good enough condition to be renovated but would need to be replaced.  Stellenbosch was able to get some additional funding as well as some in-kind help to make the new containers possible.  Concerns about acquiring the land where the new clinic would be, the full support of the local political and community leaders, and other logistical details were still not resolved.  Success felt illusive.  Yet, in the face of the many challenges, the Ukwanda team from Stellenbosch chose to dig in deeper, engaging the community, dealing with their concerns and creatively finding the resources to deal with many unforeseen issues that arose.

Freight container being prepared at Cape Town Water Front

Freight container being prepared at Cape Town Water Front

At a stage like this, I am, quite frankly, used to seeing a big university either pull back its funding and  sunset the project, or do an end run around the community and find a maneuver that would give them the legal security they need to move forward even if it does not lead to community support.  Instead of using the university’s paid legal teams to get it out of a jam, the University of Stellenbosch chose to involve its School of Law and get faculty and students from this arm of the university to research creative solutions.

This week, I paid another visit to Avian Park and I met with Prof. Hoffie Conradie, also a medical doctor whose blood, sweat, and tears have flowed into this clinic for years now.  What I saw this time was the brand new set of freight containers fully set up, painted, and functioning at about 80% of the planned use.

Avian Park New Clinic 2011

Avian Park New Clinic 2011

In addition to the original TB clinic, there is now an ARV clinic and a team of home-based care workers based out of the clinic.  Weekly physician clinic hours by Dr. Conradie are well attended and welcomed by the community.  Still to come will be family planning and other health education initiatives.  While a water line has made it to the clinic, electricity is still lacking but this is in the works and seen only as a minor inconvenience.  The clinic was bustling with activity and clearly has become a focal point of the community.

Even more impressive was that I just happened to arrive as a team from the University Of Stellenbosch School Of Sociology was just concluding an intensive study of Avian Park.  A social anthropology professor and his students had made many visits and conducted house to house interviews.  The students made use of volunteers from the community, mostly young people who assisted the students in navigating the unpaved maze of roads and any unfamiliar customs or local norms.  The result is a significant body of primary research data that will now be analyzed and synthesized to produce a profile of the community that will not only help the Medical School in its work in the community but also all the other arms of the university; agriculture, theology, social work, as they also look to begin projects in Avian Park.

Meeting later with Project Coordinator, Lindsay Meyer, in Cape Town, she attributed the tremendous cross pollination of efforts from Stellenbosch at Avian Park to the leadership of the university.   The Rector of the University of Stellenbosch has motivated and guided his faculty across all schools to develop strategic plans that have goals that are connected to the Millennium Development Goals of the United Nations.  All schools and departments are also required to have initiatives that are benefiting the community in some way.  With this kind of guidance, a university that often has so many disparate activities can instead become like an orchestra, each producing their own sound but from the same sheet of music.

Prof Hoffie Conradie addresses sociology & medical studnets and community members at Avain Park clinic

Prof Hoffie Conradie addresses sociology & medical studnets and community members at Avain Park clinic

And so it was in Avian Park. The sociology students and the medical students were each doing their own endeavors but in a way that appeared to the community and to this outsider as a coordinated effort that will build on each other.  Universities can easily become a place of many silos of information growing ever higher and rarely moving horizontally in a way that combines data for richer analysis and in a way that can most effectively benefit communities.  How refreshing it is to see what can happen when the full resources of a university are coordinated and focused to help a community.

Our hats are off to the University of Stellenbosch and its Ukwanda Rural Health Project and the Avian Park Rural Clinic for their dedication and commitment to community-based work done well!

Familiarity That Melts Away Mistrust -Michelle Obama

First Lady Howard University Jan 2011

First Lady Howard University Jan 2011

As part of the official visit of President Hu to Washington, First Lady, Michelle Obama spoke to a captivated audience at Howard University saying that when you go abroad, “you are shaping the image of America projected to the rest of the world.”  While Mrs. Obama was trying to promote a campaign to increase the number of students going to China, many of her comments are applicable to any cross cultural learning experience:

“…studying abroad isn’t just an important part of a well-rounded educational experience. It’s also becoming increasingly important for success in the modern global economy. Getting ahead in today’s workplaces isn’t just about the skills you bring from the classroom. It’s also about the experience you have with the world beyond our borders — with people, and languages, and cultures that are very different from our own.”

Last Spring, her husband, President Barack Obama, spoke to students at the University of Michigan saying:  “As our world grows smaller, more connected.  You will live and work with more people who don’t look like you, or think like you, or come from where you come from.”  And almost in a response to these words by her husband, Mrs. Obama went on to say:

That’s why it is so important for more of our young people to live and study in each other’s countries.  That’s how, student by student, we develop that habit of cooperation, by immersing yourself in someone else’s culture, by sharing your stories and letting them share theirs, by taking the time to get past the stereotypes and misperceptions that too often divide us.

That’s how you build that familiarity that melts away mistrust.  That’s how you begin to see yourselves in one another and realize how much we all share, no matter where we live.

CFHI programs have always focused on immersion into a culture, into a different helathcare system.  Rather than staging impressive extraordinary displays for students, CHFI’s Global Health Immersion Programs give students a real slice of life, giving the participant and authentic experience of what it is like to be a health professional in that country.  Some days may be very low key, other days in a hospital may be overwhelming.   Regardless of the program, the bonds that students have made with professionals, with host families and with each other are very strong and lasting.