Category Archives: Ethics

Service Learning and the Strive for Social Justice

by Robin Young
Associate Program Director, Africa and Asia

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As a nonprofit organization offering international health programs to students, is it our job to incorporate social justice into our work?

How can we bring feminist perspectives into our programming?

Does research coming out of “the Academy” in the United States apply to our partners and colleagues in the Global South?

These are the types of questions that were explored at the annual International Association for Research on Service Learning and Community Engagement (IARSLCE) conference, held in New Orleans.

IARSCLE is an international non-profit organization devoted to promoting research and discussion about service-learning and community engagement, aimed to advance understanding of scholarship from international perspectives.

At CFHI we offer service learning components in many of our programs for health students whether it is engaging with an ongoing, locally-led nutrition project in southwestern Uganda, or offering educational trainings to youth in an addiction rehabilitation center in Delhi, India. A lot of what we know about best practices in service-learning come from members of the IARSLCE community.

Mid-wife training in Port Escondido, Oaxaca, Mexico

Mid-wife training in Port Escondido, Oaxaca, Mexico

CFHI has recently played an instrumental role in bringing patient safety (and specifically, service-learning projects in which under-qualified students practice medicine beyond their level of education) into focus within the IARSLCE community, highlighting important tools such as the Global Ambassadors for Patient Safety (GAPS) modules, among others.

This year, CFHI presented a session called “From Research to Practice: Service-Learning in Healthcare Settings,” which allowed us to explore the case for general and program-specific learning competencies; explore the ethics of global health service-learning through the lens of case studies; and climb into best practices that prioritize both patient and student safety in healthcare settings abroad. As is always the case when surrounded by brilliant colleagues, it was an opportunity to share knowledge and resources and continue to think about how CFHI and other program providers can ensure that we are helping students to be prepared for their global health experiences.

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.”

The Joys of Motherhood: Sharing CFHI’s Impacts with my Children

Mother’s Day post by Jessica Evert, MD, CFHI Executive Director

It’s been said that “having kids- the responsibility of rearing good, kind, ethical, responsible human beings- is the biggest job anyone can embark on” (Maria Shriver). The challenge of mothering is monumental, yet there are precious pieces of this world that aid us in the journey. For me, one of those pieces is Child Family Health International (CFHI). IMG_7937 Jess & the kids

Through my involvement with and support of CFHI, my daughter has come to learn about a world beyond her imagination and comfort zone. I have been able to support mothers in 10 countries; community leaders who are passionate about making those struggling in their midst better off; and young people who are embarking on a transformative experience abroad that will raise their consciousness of global citizenship and make them feel a “a little softer about places that are not as economically well off,” as one CFHI Medical Director put it.

The day in and day out of mothering is a frequently overwhelming cacophony of whining, laughter, hugs, and shrugs. There are moments that intersperse our daily routine and allow us to expand our children’s worldview. These moments make us feel like super mamas. Through CFHI I am able to be the mother I want to be for my children and the children of the world.

Although my financial support of CFHI is modest, it is steady. Through this steady giving to CFHI, I am confident I am contributing to a better world. Through modeling generosity for my children, I am confident I am shaping the kind, ethical, responsible humans that I hope they will become.

CFHI Convenes Pre-health Advisors for Workshop on Global Health Best Practices

Advising Students on Health Experiences Abroad

On June 26th, I collaborated on a workshop entitled “Beyond the Basics: Advising Students on Health Experiences Abroad,” led by Child Family Health International (CFHI) Executive Director Dr. Jessica Evert and Tricia Todd, MPH, Assistant Director of the University of Minnesota Health Careers Center. The workshop coincided with the National Association of Advisors for the Health Professions (NAAHP) Annual Conference, held this year in San Francisco. Advisors arrived at CFHI’s San Francisco headquarters in to a full house with over 20 attendees representing 15 different colleges and universities. Small Liberal Arts colleges from Maine were particularly well represented, with advisors from Bates, Bowdoin, and Colby College in attendance.CFHI Advising Health Students Workshop

As a grad student of International Education Management, I was interested to observe the backgrounds represented amongst the attendees. Some were faculty in science departments, some staff from career development offices, and others from programs specifically geared towards global health. What everyone had in common was knowledge of issues relating to advising pre-health students, and all expressed worries regarding the growth of an “industry” to meet the rapidly growing demand from students seeking health-training programs abroad.

Health Students Doing Too Much, Too Soon – How to Choose Reputable Programs

The issue of the commodification of education abroad, which I was familiar with from graduate courses, took on greater significance when discussing health-related programs where issues of medical ethics and patient safety come into play. In such cases, not only are students being sold an education abroad “experience”, but unethical program providers tell students that they will be able to perform clinical work that exceeds their training and “change the world” through their work, effectively putting patients’ lives at risk.

Advisors were eager to discuss strategies for guiding students towards reputable programs and avoiding companies and experiences where students are encouraged to “do too much, too soon.” Case studies were presented, based on actual incidents from the field. Some were particularly alarming: undergraduates delivering babies, students conducting hospital rounds unsupervised, even instances of students scrubbing in for surgery! Unfortunately many students are under the erroneous impression that participating in this type of hands-on clinical experience will give them a leg-up in the competitive world of medical, nursing or other health professions school admissions. Part of the messaging to pre-health professions students therefore needs to focus on how performing clinical duties beyond what they are authorized to do here in the U.S. is highly unethical, and could jeopardize their own careers.

CFHI Advising Health Students

Before the evening was over, Dr. Evert, playing the roll of the advisor, and I, playing the part of a well meaning (but naïve) pre-med student, acted out an all too common scenario for the group. Fortunately, in our fictional advising session the student wasreceptive to ideas. The advisor convinces the student to re-examine motivations for wanting to go abroad, and suggests the right questions to ask when choosing a global health education program. The role-play emphasized the many tools available for students to examine their motivations for taking part in a health experience abroad. I think advisors in attendance left the CFHIUMN Health Careers Workshop with new resources, a feeling of community, and a better sense of how to guide students to help them make better decisions for their global health education.

 

Special thanks to our guest blogger, CFHI Intern Alex Nichol, for authoring this post.

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 Commended in Chronicle for Higher Education Article

 

From the Chronicle of Higher Education:

“Over the past decade, the number of American students in health fields going abroad has nearly tripled, with many opting for programs that take them out of the classroom and into clinics and hospitals. But as participation has increased, so, too, have educators’ concerns.

Far too often, experts say, students are providing patient care—conducting examinations, suturing wounds, even delivering babies—for which they have little or no training. Indeed, as competition intensifies for medical-school slots, some students may actually be going overseas for hands-on experience they could not get in the United States, in hopes of giving their applications a competitive edge.”

The article is entitled “Some Global Health Programs Let Students Do Too Much, Too Soon,” and here at Child Family Health International (CFHI) we couldn’t agree more!

CFHI India Student on ProgramCFHI programs are highlighted in the Chronicle article, including quotes and reflections from CFHI’s Executive Director encouraging students to think about ethical implications of their experiences, and shaping student expectations for what is ok to do abroad.

As the field of global health continues to grow, so too are programs and options available to health students of all fields, often promising opportunities to “help” and engage in hands-on experience beyond their training, skill level, or licensure.  From the beginning CFHI has used an asset-based approach for engaging with communities abroad, and encouraging students to “Let the world change YOU.” In this way we position participants of Global Health Education Programs to learn, reflect, and realize that many times the most powerful impact they have in their role abroad is to form connections and relationships with local expert physicians and patients that will serve them in their future careers, as well as learn about the multitude of health determinants and complex global realities that underlie global health challenges.  We’d like to extend a big thank you to the Chronicle of Higher Education for helping us spread the word and advocate for social responsibility in health and medical education.

What do you think should be students’ role in health settings abroad?  How can students balance enthusiasm for learning while respecting ethical boundaries in clinical settings?  Let us know your thoughts in the comments section below.

CFHI: Asset-Based Community Engagement

Child Family Health International (CFHI) at 20 years old continues to be the gold-standard in forward thinking and innovative frameworks in global health education.  CFHI provides community-basedsmall-logo2_png education alongside local professionals via clinical and public health experiences for students and those interested in learning more about medicine and health-related fields, with more than 20 programs in 6 countries.  Programs cover a variety of topics from maternal health to palliative care.

What Makes CFHI Different?

After all these years CFHI remains unique, continuing to challenge paradigms in global health and advocating for local communities. CFHI partners with communities that are considered low-resource and underserved by global financial standards.  Rather than focusing on what is lacking, however, CFHI helps to identify community strengths, ingenuity, and passion.  In close collaboration with local teams, CFHI creates programs and funds community health projects identified and carried out by local teams. This practice is based on the asset-based community development approach, formalized at Northwestern University.  The CFHI approach positions local health practitioners and patients as the ‘local experts’—presenting global health realities through authentic experiences that help shape and transform young people who are interested in global health, equity, and global citizenship.

CFHI Student with Dr. Paul, Rural Urban Himalayan Rotation

CFHI Student with Dr. Paul, Rural Urban Himalayan Rotation

Not Just Talking the Talk, But Walking the Walk

Importantly, CFHI is a staunch proponent of compensation for local community contributions and practicing financial justice.  Uniquely CFHI, 50% or more of student program fees go directly to the communities they will be visiting, benefiting the local economy at large and specifically undeserved health systems.  CFHI is an active affiliate of Consortium of Universities for Global Health, United Nations ECOSOC and has authored literature about global health educational curriculum development at undergraduate and graduate levels.   CFHI encourages students to “Let the World Change You” in preparation for being a part of socially responsible, sustainable change they wish to see in the world.

Turning Dark Profits into Enlightened Transformation

From Skepticism to Hope: Turning Dark Profits into Enlightened Transformation

I’ve been a doctor now for 13 (lucky) years but I recently had the opportunity to reflect on my path towards becoming a physician and my involvement in Continue reading

How Can We Think Globally & Act Locally?

Phrases like “Think Global, Act Local” and “Global Health is Local Health” are catchy, but it’s sometimes difficult to figure out what they really mean. 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

Trends in Global Health Education: UT Health Science Center, San Antonio

UT Health Science Center, San Antonio Houses Global Health in the Center for Ethics

It’s interesting to consider where a university or medical school chooses to house their Global Health efforts and how this affects the focus and framework of global health activities.  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 Listed in USA TODAY as Trusted Charity

Today the editors of USA TODAY added a Special Section to their national newspaper called Sharing in the USA.  This is an annual attempt to focus on charitable giving.  Included in this section is a list of national charities that have earned the Seal of the Better Business Bureau as an Accredited Charity.  Of all the nonprofit organizations in the USA, only about 300 have met this set of rigorous and comprehensive standards that are independently researched and verified by the Better Business Bureau in Washington DC.  The 20 standards cover Governance, Fund Raising Practices, Finances and Financial Reporting, Donor Privacy and Transparency of national charities.

CFHI is proud to be a Seal Holder of the BBB and to have, once again, made this list.  It is a testament to the hard work of our Board of Directors and our Staff who are dedicated to the highest standards of nonprofit management striving to run socially responsible programs with accountability and transparency.  All the national Seal Holders are listed on the full page ad under the banner headline: Give With Confidence.

The BBB calls this the Wise Giving Alliance Accreditation Standards and issues a report on national charities which is visible on their website.  This is an effort to offer a resource to help those who want to research their charitable giving and have some independent verification of the claims that a charity might make.  You can see the report for CFHI as prepared by the BBB earlier this year.

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.

World Food Day

United Nations World Food Day

World Food Day

Today is World Food Day.  The United Nations Food and Agriculture Organization has issued a report that should be on the ‘must read’ list of anyone interested in global health.  There is some good news but also some disturbing news that should act as a wakeup call for the world community.  Staple food prices are at or near all time highs.  One of the most alarming facts in the report entitled Food Prices From Crisis to Stability is that just since last year the increases in the cost of basic food has, “pushed nearly 70 million people into extreme poverty.” 

 

Past Successes Have Not Kept Pace

The report points out that while the world’s population doubled between 1960 and 2000, there were significant advances in agriculture that allowed food production to “meet and even exceed demand in many countries.”  Unfortunately, the investments in research that were made, by both rich and poor countries, to produce the much needed innovations have not been maintained in recent decades.  There has been a 43% decrease in government spending on research and development in the area of agriculture in the last 30 years.  Therefore while the population of the world continues to increase, food production has not kept pace.

The last time food prices were this high was in 2008, when the price of various staple foods shot up very quickly and there was rioting in over 20 countries as a result.  Certainly the global

FAO Food Price Index October 2011

FAO Food Price Index October 2011

economic situation is in even less shape to deal with record high food prices today.  What’s worse is that due to the inability of food production to keep pace, “The global market is tight, with supply struggling to keep pace with demand and stocks are at or near historical lows.”

 

Promising New Successes

While the report warns that food price volatility may become an unsettling fact of life for the foreseeable future, it also gives some success stories that offer great hope.  If we can prioritize research and development and scaling of existing successes, we may be able to prevent some of the volatility that now seems inevitable.  Some scientific advances in Africa and Asia are resulting in higher yields but much more needs to be done in this area.  Some countries have made increasing their food production a priority by encouraging agricultural land use and supporting research.  Other countries like Mexico have been proactive in targeting assistance to some of the 70 million globally who are the new poor.  Through carefully monitored programs tied to the education system, the Mexican government has been able to provide assistance to one in four families who have been hardest hit by rising food process.  Even in these difficult times, this effort has, “…been credited with improving the health of children and adults, and raising nutrition and school enrollment levels.”

As we advocate for improved basic healthcare, we must also advocate for smart basic development that learns from the past and is doing the necessary research to keep up with our current and future needs.  For the cornerstones of global public health continue to be water, food, sanitation, and education.

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.

 

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!