Author Archives: Robin Young

Virtual Practicums: Following Best Practices to Prevent Neocolonial Voluntourism

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By Victoria Sevilla

Victoria Sevilla was a Virtual Global Health Practicum Intern for CFHI Philippines in February 2022. She was mentored by Associate Medical Director Paolo Victor Medina, MD. Victoria received her Bachelor’s in Global Health from the University of Southern California (USC), and will earn her second degree in Biological Sciences this year. She credits GlobeMed at USC for catalyzing her dedication to health equity and social justice, but the scope of her activism has since expanded. Victoria holds positions in Right to Health (R2H) Action, a grassroots health policy organization, and the American Medical Women’s Association (AMWA). She is also a member of the American Medical Student Association (AMSA) and the American Public Health Association (APHA). 

For years, I’ve longed to work with CFHI due to their sustainable model with fair-trade partnerships and asset-based community engagement. My undergraduate work with GlobeMed at USC emphasized the importance of responsible global health collaborations, especially avoiding volunteer tourism or “voluntourism.” Despite ramifications to the local communities, traveling to lower- or middle-income countries to “help the less fortunate” is a swiftly growing trend.

Having native Tagalog fluency, I knew my capacity to contribute a culturally-sensitive impact was expanded should I participate in CFHI’s Global Health in the Philippines program. I also understood, however, that my experiences greatly differed living in the United States. In addition to limited financial resources as a student, I did not feel qualified to travel to and volunteer in a country I had not visited since childhood. So upon learning of CFHI’s virtual programs, I was excited for the opportunity to broaden my global health competencies without infringing ethical dilemmas.

Voluntourism is not limited to eager tourists and also extends to the medical community. Historically, medicine has been used to biologically justify racial supremacy.1 As a result, colonizers excused medical research on native populations and the eradication of their history, culture, and language.1 Today, healthcare professionals could perpetuate this colonial legacy by performing medical procedures typically beyond their scope of practice.1 For pre-medical students, volunteering abroad is part of the “pre-med” checklist to look better on medical school applications, all while gaining clinical experience not otherwise allowed in the United States. These undergraduates, untrained and unqualified based on American standards, capitalize on the opportunity with minimal or no accountability.

Though “voluntourists” claim altruistic intentions, a “White Savior,” capitalist-colonial subjectivity remains.2 Voluntourism not only reinforces distorted power-dynamics between countries and disrupts local economies, it coerces those already resource-strained to adapt.4 Medically, cultural differences and language barriers severely compromise patient safety, especially in rural communities where access to care is scarce.1 Pre-health students are most dangerous, some having been allowed to diagnose patients, write prescriptions or perform medical procedures by themselves.3 And with more and more natural disasters and extreme weather, the demand for these “humanitarian expeditions” is predicted to increase.4 Another layer of complexity are the growing concerns about the misuse of technological advances where “virtual volunteerism” could become another mode of exploitation.4 For these reasons, voluntourism is really a form of neocolonialism.

So where does this leave global health students? How do we gain real-life experiences without partaking in the unethical practices we advocate against? We are not excused from “intellectual tourism” simply because of our academic status.5 Thus, Withers et al. (2018) and the Association of Pacific Rim Universities (APRU) identified the major obstacles faced in academic practicums and established best practices in response.5

Major Challenges:5

  1. Sending vs Host Institution Disputes
  2. Language and Cultural Differences
  3. Intentional or Accidental Misconduct
  4. Unequal Benefits from Partnership
  5. Inadequate Mentorship
  6. Student Financial Disparities
  7. Practicum Value
  8. Physical Safety

Best Practices Recommendations:5

  1. Competitive Student Selection
  2. Transparency on Objectives and Expectations
  3. “Pre-Trip” Orientation
  4. Pre‐requisite Training
  5. Financial Aid
  6. Mutual Benefit and Reciprocity
  7. Pertinent Mentorship
  8. Program Assessments

CFHI’s model ensures these challenges are addressed and best practices maximized. With the help of ​​Dr. Juliana Araya Amador (CFHI Practicum Coordinator) and Dr. Paolo Victor Medina (CFHI Philippines Associate Medical Director and Practicum Preceptor), I was confident my actions were not only ethical and sustainable, but also exemplified the cultural humility CFHI values.

In addition to practicing and teaching Community Medicine as an Assistant Professor at the University of the Philippines College of Medicine, Dr. Medina is the faculty liaison officer to the town of Ternate under the MAGNAMARTE-UP Community Health Partnership Program. With guidance from Ternate’s Municipal Health Officer and based on the town’s current needs, Dr. Medina designed my project to study vaccine hesitancy. The practicum objectives, key responsibilities and expected deliverables were clearly communicated, and all of my questions immediately addressed. At the “pre-trip” orientation stage, online modules included analyses of my cultural profile and intercultural effectiveness, identifying the cultural differences I should be most attuned to. Most valuable of all is Dr. Medina’s impeccable mentorship. His patience and thorough guidance ensured my academic, professional, and personal development surpassed its potential.

Contributing to equitable healthcare delivery to vulnerable populations is an indescribable honor. Currently, there is minimal literature on Filipino COVID-19 vaccine hesitancy, and rural communities are especially at the margins. Working with the citizens of Ternate, we hear their causes for concern and factors in decision making. Promoting open discourse allows us to strategize the best, next steps forward with the local government. Though the 16-hour time difference minimizes direct resident interactions, Dr. Medina and I are able to use it to our advantage. Completing the investigative analysis in my time zone maximizes the field team’s reach in the community. We are literally working around the clock! This efficiency is made possible by the virtual platform and has promising applications for interdisciplinary collaborations.

As Dr. Mellissa Withers’s (APRU Global Health Director) former student, I have had the privilege of her instruction and guidance. Discussing virtual global health practicums and the applicability of APRU’s Best Practices, she supports the expanded accessibility for students. She does not believe it perpetuates neocolonial volunteerism because performative tourists driven by a savior mentality will prefer traveling in-person. Dr. Withers concludes that the ultimate gauge on responsible global health engagement depends on the hosts’ investment and if it strains their resources.

CFHI’s virtual programs allowed international partnerships to progress at a time where borders were closed, but global health collaboration even more dire. This innovative response to the pandemic demonstrates how ethical and sustainable practices can be maintained despite society’s thrust into survival mode.

Learning from esteemed leaders such as Dr. Medina, Dr. Withers, and Dr. Araya is an unbelievable privilege, and I am beyond grateful for the opportunity CFHI has enabled. This practicum experience is a comprehensive application of the competencies I’ve learned, and I hope to participate in an on-site rotation in the future. For students concerned with the wider implications of their global health involvement, CFHI’s well-established infrastructure is a testament to their mission towards responsible engagement.

References:

  1. Eichbaum, Q.G., Adams, L. V., Evert, J., Ho, M-J., Semali, I. A., & van Schalkwyk, S. C. (2020). Decolonizing Global Health Education: Rethinking Institutional Partnerships and Approaches. Academic Medicine, 96(3), 329–335. https://doi.org/10.1097/ACM.0000000000003473
  2. Everingham, P. & Motta, S. C. (2020). Decolonising the “autonomy of affect” in volunteer tourism encounters. Tourism Geographies, 1–21. https://doi.org/10.1080/14616688.2020.1713879
  3. Evert, J., Todd, T., & Zitek, P. (2015). Do you GASP? How pre-health students delivering babies in Africa is quickly becoming consequentially unacceptable. The Advisor, 61-65.
  4. Ong, F., Lockstone-Binney, L., King, B., & Smith, K. A. (2014). The Future of Volunteer Tourism in the Asia-Pacific Region: Alternative Prospects. Journal of Travel Research, 53(6), 680–692. https://doi.org/10.1177/0047287514532365
  5. Withers, M., Li, M., Manalo, G., So, S., Wipfli, H., Khoo, H. E., Wu, J. T., & Lin, H. H. (2018). Best Practices in Global Health Practicums: Recommendations from the Association of Pacific Rim Universities. Journal of Community Health, 43(3), 467–476. https://doi.org/10.1007/s10900-017-0439-z

Breaking the Cycle of Malnutrition

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“My name is Shirley Yang. I am a CFHI intern, working virtually with CFHI’s Ugandan partner organization, KIHEFO. In this op-ed, I explain the importance of nutrition education in breaking the cycle of malnutrition and clarify misconceptions about causes and effects of malnutrition. After providing a brief overview of active nutrition programmes, run by both the Government of Uganda and international humanitarian organizations, I offer suggestions about how to improve the system based off of my own research and meetings with my supervisor, Dr. Geoffrey Anguyo. “

The role of nutrition education in promoting healthy diets cannot be underestimated. Malnutrition is not characterized solely by lack of food, but also lack of knowledge of available food. Malnutrition, especially in childhood and pregnancy, can have detrimental consequences on one’s long-term well being. The negative effects are not confined to an individual; they will eventually seep into the community and country, affecting human capital availability, economic productivity, and national development. 

In recent years, Uganda has made strides in reducing poverty levels and undernutrition rates. However, malnourishment continues to threaten the Ugandan population as half of children under five and one quarter of child-bearing age women are anemic. To add on, more than one third of all young children suffer from stunting, a consequence of inadequate nutrition and care. There are many factors that drive malnutrition in Uganda, including early motherhood, lack of family planning, lack of access to clean water and sanitation, child diarrhea and malaria, and poor infant and young child feeding practices. 

To break the cycle of malnutrition, organizations are focusing on addressing the nutrition needs of the young child from conception through about 24 months and ensuring the nutritional well-being of the mother before she becomes pregnant. There are numerous movements, initiatives, and campaigns sponsored by the Government of Uganda as well as international humanitarian organizations addressing malnutrition in Uganda, such as the Scaling Up Nutrition (SUN) Movement, Comprehensive Africa Agriculture Development Programme (CAADP) Compact, and Preventing Child and Maternal Deaths: A Promised Renewed. 

As outlined in the Uganda Nutrition Action Plan (UNAP), the Government of Uganda is implementing a multi-faceted approach to eradicating malnutrition by addressing nutrition, agriculture, and food security simultaneously. UNAP focuses on improving maternal, infant, and child nutrition, increasing production of and community access to micronutrient-rich foods, and advocating for increased resources dedicated to nutrition intervention. 

Various USAID programs focusing on improving nutrition in Uganda are also utilizing a multi-faceted approach. For instance, HarvestPlus Meals for Nutrition in Uganda (MENU) focuses on increasing production and consumption of high-yielding iron-rich food such as beans and pearl millet. Such programs operate in rural areas as 84% of the population reside in rural areas and agriculture continues to be the main source of income for the majority of Ugandans.

Nutrition educational practices that directly involve the target audience, whether that be children, their caretakers, or pregnant women, have proven successful. For instance, a program promoting exclusive breastfeeding of infants that included peer counseling for mothers before and after giving birth resulted in increased rates of exclusive breastfeeding for children whose mothers received counselling compared to children whose mothers did not receive counselling. This sentiment is shared by my host organization KIHEFO. 

As shared by former KIHEFO interns through blog entries, “What’s on Your Plate” is an interactive hands-on activity built from KIHEFO’s Nutrition Guide. By inspiring participants, ranging from primary school students to caretakers, to diversify their diets by incorporating locally accessible foods that belong to the five different food categories quintessential for a balanced diet. Additionally, during our meeting this week, Dr. Geoffrey shared an instance in which a young child was severely malnourished and the KIHEFO nutrition center successfully rehabilitated the child using a vegetarian-diet. By telling this case, Dr. Geoffrey emphasized the importance of clarifying misconceptions; in this instance, he clarified that nutrition rehabilitation does not require meat, which most households only consume two to three times per year. This instance reinforced the importance of nutrition education — specifically, the importance of recognizing the importance of eating foods from different food groups to acquire sufficient macro- and micronutrients. 

The multi-sectoral strategy that the Government of Uganda and various humanitarian organizations are undertaking is very comprehensive. However, research has shown that postpartum counselling on breastfeeding is lacking. Although three-quarters of women delivered in a health facility in 2016, only 35% received postpartum counseling on breastfeeding. The disparity indicates that the health system is not taking full advantage of contact points to deliver high quality services. This trend could also extend to other health services provided by health professionals. 

During our meeting this week, Dr. Geoffrey continuously reinforced the importance of reaching out to churches, as the majority of Ugandans rely on spiritual leaders. Outreach is a critical component of ensuring the general public is properly educated on nutrition. Allocation of sufficient funds to outreach and communications is critical. Increasing points of communication, such as at churches and delivery centers, between health professionals and nutritional programme personnel with the general public is quintessential. By connecting with community hubs, nutrition education can be more readily available to the general public.

 

Nutrition Education in India

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“Hi! My name is Emily and I’m a rising sophomore in the Chemistry department at Princeton University. I’m also hoping to pursue certificates in Neuroscience and Consort Singing. I;m currently interning at CFHI to further my knowledge of public health, as it has always been a passion of mine outside of the classroom. As a pre-med student, my work with CFHI India has been of interest to me, and I greatly enjoyed writing this op-ed about nutrition in India. I hope you are able to get a glimpse of how healthcare and nutrition differs in India.”

Preventable diseases such as nutritional anemia, undernutrition, and obesity are a large burden on India’s adolescent population and healthcare system. Paradoxically, nutrition education is disproportionately lacking and is in dire need of improvement. Nutritional anemia affects almost 90% of poor children, adolescent girls, and women. In both urban and rural areas, many kinds of undernutrition are prevalent- every fifth adolescent 10-14-years is Vitamin A deficient, every third adolescent girl is B12 or folate deficient, and at least 1 in 3 adolescents is zinc deficient. In recent years the prevalence of both undernutrition and overnutrition/obesity have increased tremendously and are estimated to affect the health and quality of life of about 1.2 billion Indian citizens. A preventable illness, obesity has compounding effects as it increases likelihood for diabetes, cardiovascular disease, and a plethora of medical complications down the line.

But why the sudden change? Diet! Research has shown that most adolescents consume nutritionally inadequate diets characterized by a surplus of fats and sugars, and lessening consumption of fruits and vegetables. Fast food and junk food products like potato chips and sodas have become increasingly common, slowly replacing more traditional home-cooked staples. This is due in large part to urbanization. The burden of preparing meals and passing down cooking traditions falls largely on women, who are increasingly working out of the household, leaving less time to prepare healthy foods. To compensate for this cultural shift, processed foods have become more accessible in convenience stores and fast-food restaurants. In addition, school cafeterias often do not provide nutritious meals.

India’s next generation is faced with multifaceted nutrition deficit- a culture popularizing fast food, less traditional cooking knowledge and skills, accessibility of nutritionally inadequate foods, and insufficient nutrition education to help them realize the problem. Indian schools do not prioritize health education, instead focusing on natural sciences with an emphasis on rote learning. When nutrition is taught, it is typically taught as a part of a home sciences curriculum, which is often optional and not comprehensive. Again, the onus falls on girls and women to carry out this vital role. Most home sciences teachers are women, enrollment is substantially higher for girls, and the prevalence of home sciences courses is higher in all girls’ schools. In keeping with India’s academic culture, what courses are available are typically focused on memorization and fail to impart the critical thinking skills required to make informed nutrition decisions outside of the classroom. What results is a generation with an increased prevalence of a vast array nutrition related conditions on both sides of the spectrum, and no skills to combat them.

Various government and independent initiatives have tried to bridge this gap. Organizations like UNICEF focus on the first 1000 days of a child’s life to prevent stunting, as well as the adolescent girl population. Many other NGOs provide similar aid focusing on mothers and children in the form of folic acid supplements for pregnant women, counselling on breastfeeding, and micronutrient rich snacks to mothers and children. In 2001, the government launched a new initiative. The supreme court of India directed the government of India to provide cooked midday meals of no less than 300 kilocalories and 8-12g protein in all government and government-aided primary schools.. It has been estimated that daily nutrient intake of program participants increased by 49%, and with a cost of just 3 cents per child, the program reduced daily protein deficiency by 100% and calorie deficiency by  30%. The most dramatic improvements were made by those in the most dire states- children chronically affected by drought and very young children. The intervention yielded promising results, but unfortunately in the case of most participants, no long term affects were found.

The problem runs deep into the culture surrounding nutrition education. Indian academia also lacks an emphasis on nutrition. There are currently only 190 institutes in India that offer one or more nutrition courses. The discipline of public health nutrition does not exist as an independent discipline in any college/university across India. Culturally, the role of nutritionists is often seen to be limited to treating specific maladies on a case by case basis.

There is a resounding consensus among students, parents, teachers, and doctors alike that this is taking a toll on youth, yet action on all fronts has been insufficient. Undernutrition of children has lifelong impacts on cognition, which can affect career prospects in adult life. For these reasons, UNICEF recognizes ending undernutrition as a “national imperative.” A possible solution lies in shifting the culture around nutrition in the government and education sectors. It is necessary to institute policies that empower the people and shift the onus of nutrition from ill-equipped teens to large corporations. This could include taxing large fast-food chains with respect to how much fatty, fried food, sugary food, and large portions they serve. It could also  offer coupons for meals which qualify as nutritious under certain standards that could be used at restaurants and stores. Nutritional supplements could be provided free of charge to all children and expectant mothers. To empower people to make informed decisions about their diet, all schools should teach a comprehensive curriculum to all students covering exercise, diet, financing food, and cooking. This would lessen the disparity of responsibility between women and men, which would provide families with more hands in the kitchen capable of providing healthful homecooked meals. What India needs is a shift in the culture around nutrition studies. Entering the public health nutrition field could be incentivized and schools encouraged to consult with nutritionists when creating school lunches. This would shift the focus of nutrition to harm prevention rather than overburdening the healthcare system with preventable diseases like obesity and malnutrition.

Participant Perspectives: Hospital Medicine in Coastal Ghana

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Every year, dozens of students and trainees head to Ghana to participate in CFHI’s Hospital Medicine in Coastal Ghana program, where they are immersed in a new culture while participating in observational clinical rotations at the Cape Coast Teaching Hospital under the supervision of a team of local preceptors. This post chronicles the experience of four CFHI trainees who participated in this program in 2019 and 2020. During their time in Ghana, they shadowed medical professionals in various departments within the hospital, visited historic landmarks, and broadened and enriched their medical and socio-cultural knowledge. 

Shashank Singh

Shashank Singh, an Undergraduate Environmental Public Health student at Ohio State University, rotated in four different departments at the Cape Coast Teaching Hospital. This experience gave him a great introduction to the Ghanaian healthcare system and its many different facets. He noticed that lack of access to clean water was a recurring problem within the hospital, and this disparity made Shashank realize that water quality is an urgent public health issue that still afflicts many regions of the world and helped to deepen his understanding of determinants of health. He also got the chance to participate in an outbreak event where he accompanied local healthcare workers into the community to provide pop-up clinic services and assisted in health education campaigns. He thought that going into the community was a great intervention and appreciated the opportunity to learn about locally-based initiatives to provide care to those who usually do not have access to health care.

Ka’la Drayton

Ka’la Drayton is a fourth-year medical student at the Medical University of South Carolina. During her first couple of weeks at the Cape Coast Teaching Hospital, Ka’la rotated in both the OB/GYN and internal medicine departments. During her rounds with OB/GYN specialists, she shadowed local healthcare professionals as they tended to emergency room visits, cesarean sections, removal of fibroids, ovarian cancer treatments, and more. While rotating in the internal medicine department, Ka’la was able to witness a variety of different cases such as a hemorrhagic stroke, Mallory-Weiss tear, cirrhosis, spontaneous bacterial peritonitis, and HIV encephalopathy. Her experience gave her a better understanding of the local and global burden of disease as well as how communities are able to remain resilient despite scant resources and  innovate to address local issues such as sanitation, water supply, and electrical outages. Ka’la wrote, “Though their resources are limited they know exactly what to do and how to do it but unlike home, all of those things aren’t laid out beautifully in our Pyxis bin.” Learning more about the healthcare system in a different country allowed Ka’la to compare and contrast her experiences with those in America. 

Even though Ka’la is a trainee from the US, she felt right at home in Ghana. She wrote, “I went from being the only African American during rounds in America to now being the only African American amongst Ghanaians here, and it’s life-changing. Being among people who look like me and are treating people who look just like them, made me so proud.” The local healthcare professionals and staff made her feel very welcomed, shared stories, and bonded over how they share the same issues when it comes to getting consults or referrals from other hospitals. 

Kristin Forkapa

Kristin Forkapa is a fourth year medical student at Ohio University Heritage College of Osteopathic Medicine. During her program in Ghana, she spent two weeks in the pediatric ward and two weeks in the internal medicine ward. Kristin noticed many differences in the healthcare system between Ghana and the US. For example, she noted that in Ghana, one pays for treatment before receiving care, whereas in the US, care is  administered first and then the bill comes after. She also noticed that the relationships between students/residents and attending physicians is much more relaxed in Ghana and has forged lasting friendships with her mentors and fellow trainees. 

Her CFHI experience allowed Kristin the chance to learn the history of Ghana and culturally immerse herself in the local community. On a weekend trip, Kristin visited the Cape Coast Castle — an important landmark in Ghana and where roughly 214 million Africans had been held during the slave trade. A lot of her free time was spent going to the local markets almost daily or visiting her friends family members who live in Ghana. She particularly enjoyed the food – especially the jollof, kenkey, stew, and kebabs.

Jerica Gibson

Jerica Gibson is a Medical Student at Philadelphia College of Osteopathic Medicine. She spent one week in Internal Medicine, one week in a CHPS compound (Community-Based Health Planning and Service) and two weeks in the Pediatric Ward at Cape Coast Teaching Hospital. During her time at the CHPS compound, she shadowed the local staff on  family planning sessions, general consultations, and pediatric check-ups and vaccination. While shadowing residents in Internal Medicine, she came across many ailments such as Deep Vein Thrombosis (DVTs), Malaria, HIV, and Meningitis. This was a new experience for her, as the U.S. has a very different burden of disease and many of these communicable diseases are less present.

Jerica also visited the Cape Coast Castle where she was able to learn about the history of Ghana during the 1600s. In her blog she writes: “It shed light on the slave trade from a different perspective that is not often taught appropriately in the US.” Seeing the Cape Coast Castle in person was very impactful for her and allowed her to learn a lot more about the transatlantic slave trade from a different viewpoint.

Like other CFHI participants in Cape Coast, Jerica witnessed and confronted challenges within the healthcare system such as unsafe water quality, lack of hospital funding, and inadequate access to health services. As someone who has spent a lot of time advocating for better healthcare in the US, this experience opened her eyes to the inequalities that exist elsewhere too. She hopes to continue learning and advocating not just for equality of healthcare in the US, but around the world. 

While each participant’s experience is different, CFHI global health programs in Ghana provide a rare chance for students and trainees in the health and medicine fields to learn and experience what health looks like in a different context and learn from local health leaders while culturally immersing in the communities that they serve. Participants emerge from their programs with a better understanding of health and its determinants, a network of peers and mentors, and a deepened sense of self and service.

CFHI’s programs in Ghana are now being offered virtually- check out virtual internships and virtual practicums here. All of CFHI’s Virtual Opportunities can be found here: https://www.cfhi.org/virtual-opportunities

Partera Influence on Health and Culture in Mexico | A Personal Story

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This piece was written and contributed by CFHI participant Carmen Simmons, who was a Medical Student at Meharry Medical College when she participated in the Women’s Reproductive Health program in Puerto Escondido, Mexico in 2018.

When first arriving at the Centro de Salud, I have to admit I was proud of myself. I had managed to find the right colectivo in a mountainous countryside in the quaint town of Río Grande. After exchanging various “Buenos Dias”, I made my way over to partera, traditional midwife, Señora Lucia Zaguilan Mayoral.

At our first meeting, Sra. Lucia patiently listened to my never-ending questions in – let’s be honest – broken Spanish. When she spoke I struggled with the speed of her words. After some compromise on both of our parts, we found a tempo that worked for us to communicate.

Sra. Lucia calls Colonial Villa De Tututepec home and is a Rio Grande native. She has been attending births since she was 13 years old (today she is 63). Coming from a long line of parteras, she started learning as her grandmother’s apprentice. To this day, her family is filled with an impressive variety of healthcare workers.

She has attended conservatively well over 5,000 births. INCLUDING HER OWN CHILD’S! Yes, that’s right, she delivered her own son. She recounted the story to me while laughing at its ridiculousness. In her last days of pregnancy, she was in the kitchen cooking when her contractions started getting too close for comfort. She can’t exactly remember why no one was home, but nonetheless she had her abundant knowledge of births to comfort her. As calm as anyone could be while delivering her own child, Sra. Lucia guided her son toward the light of life. She even cut the cord herself! By the time her family came back home, they were greeted by a nursing newborn.

During the partera training I was able to witness, Lucia reflected on the immense amount of knowledge her grandmother bestowed onto her. This particular partera training is an annual training co-facilitated by Child Family Health International, local staff and a group of Northwestern students in partnership with the Oaxacan Ministry of Health. As a young girl, Lucia learned many techniques from her grandmother including monitoring her patient’s hair, skin, and eye color and the various methods of moving a baby into the correct position for delivery.

At the partera training, I immediately noticed that all of the women were 60 years or older. I asked her what she thought had changed in the last 20-30 years since she began practicing as a partera to account for this . She comments that she, and others, have noticed a change in attitude with the younger generation. She states that “most young women (under 35) are scared of anything to do with childbirth. Many want cesareans now. And the others are too afraid to learn to be a partera.” The sociopolitical context on the increasing cesarean rate in Mexico is interesting in itself. Approximately 39% of all hospital births in the state of Oaxaca were cesarean births. The World Health Organization states when the cesarean rate goes above 10%, there is no evidence that mortality rates improve.

During my time with Lucia and other parteras, I learned of the integral role that Parteras play in women’s health in Mexico although it seems to be an aging profession. I also learned about the scarcity of resources (financial, equipment, etc.) that the parteras face and overcome daily in their work. I fear that communities will not truly understand the immense importance of their role until there are very few left. My hope is we don’t wait until then, and find a way to revitalize younger generations to strengthen the tradition and empower the existing parteras.  

The LGBTQ+ Population in Uganda

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Homosexuality is illegal in Uganda, but homosexuality is also illegal in 69 other countries worldwide, and the practice of labeling individuals as homosexual, gay, or lesbian was traditionally not a part of Ugandan culture. This topic was not politicized, and Ugandans accepted different practices. Recently, however, LGBTQ+ Rights in Uganda have become a prominent issue in politics and in the international media. In 2009, MP David Bahati proposed the Anti-Homosexuality Bill and in February 2014, it was signed into law by President Museveni. The Ugandan constitutional court struck down the law in August 2014, but civil rights activists say the situation for LGBTQ+ Ugandans is still worse than it was before the law. LGBTQ+ individuals, numbering around 500,000 in Uganda, often face consequences if they reveal their identity, so discussions about sexuality are rare.

While in country, focus on your safety and trust your gut. It is usually best to avoid questions about your sexuality and be ambiguous if asked. Please respect the local culture and assess who you are speaking to. Also, remember that travelers to Uganda often don’t face the same discrimination that locals do. As someone with “tourist privilege,” you may have slightly greater freedom of expression, but your actions may have repercussions for the locals you engage with, so please take that into consideration.

Traveling is always challenging, and LGBTQ+ individuals often face additional levels of complexity. The followingresources will help you to educate yourself on the local culture and social context. There are a wide range of resources available that will allow you to better understand the political climate and cultural nuances of a country. Some resources to explore include: ilga.org, the US State Department, the Geert Hofstede Center for Cultural Insights, the CIA World Factbook, alturi.org, ilgta.org, and HSBC Expat Explorer. It is also a good idea to register yourself with the State Department so they’re in a position to advocate for you. Staying in touch with friends and family back home who know your identity often helps travelers as well. Skype, Whatsapp, and Viber are good options for this.  

We also want to make explicitly clear that CFHI does not agree with or condone any discrimination based on sexuality. Our partners in Uganda are welcoming and do not practice discrimination, and students have not experienced any issues in the past. However, understanding the local context regarding LGBTQ+ rights will help ensure that there are no incidents in the future.

For more information, please refer to the following sources:

The OSAC LGBTQ Guide to Travel Safety

The State Department’s Website for LGBTI Travelers

The Human Rights Watch

The International Policy Digest’s Article on the Origins of Uganda’s Anti-Gay Law

Why Global Health Ethics Matter: A Personal Story

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Image result for antigua guatemala

In the summer between my sophomore and junior year of college (undergraduate), I participated in a medical volunteering program for 2 weeks in Antigua, Guatemala. As a pre-med student, I knew I wanted to do something during my summer that involved medicine and figured volunteering in a hospital or clinic would be my best bet. Unfortunately because I had a mostly full time job, I was unable to secure any type of volunteering program locally since they all required a certain amount of hours that I would not be able to complete before returning to my university in the fall.

I then decided to look online at volunteering abroad, and found a myriad of programs that fit my time constraints perfectly. I honestly did not do too much research and just clicked on the first organization I found that had a solid amount of positive reviews and wasn’t too expensive. Looking at the cheapest options, I saw that in Latin America they offered an affordable medical program in Guatemala. While scrolling through the program description, the phrases “gain hands on experience” and “provide check-ups and basic medical care” piqued my interest as the idea of actually getting to perform medical procedures sounded incredibly appealing to myself as a student interested in a career in medicine. I imaged working in a hospital with doctors and nurses and getting the opportunity to experience medicine directly. The program description made it seem that these “poor” communities needed any help they could get, so I figured that I could kill two birds with one stone-help this underserved country while also gaining medical experience. Even though there were red flags consistently throughout the program description-the program oozed “voluntourism” and provided very brief and limited information on what actually would take place during participation- I wasn’t suspicious at all because I didn’t expect anything that involved volunteering to be problematic.

After signing up, there was a very brief pre-departure guide I had to complete before embarking on my trip. The guide was just a general guide and mostly focused on the logistics of getting there (ie. visas, packing list, etc.). There was a short list on my responsibilities, but it didn’t really mention anything about ethics. There were also 2 optional pre-departure training modules that were more informative on ethics, but were brief and took less than 30 minutes to complete. I didn’t really feel that prepared for my program, but figured I would get more instruction and guidance once I arrived.

Once I finally made it to Guatemala, I started to see problems and holes within the program. Before starting my rotation, I met with the medical coordinator for the program to have orientation. The orientation was pretty short and consisted of a powerpoint on the kind of care we could provide. After telling him I had had no prior experience in medicine, he told me that I would act somewhat like a nurse, taking weight, height, blood pressure, heart rate and temperature, making beds, cleaning, talking with patients, preparing materials and sterilizing equipment. Even though I told him I didn’t know how to take blood pressure or heart rate, he assured me the other visiting volunteers at the clinic would teach me. This orientation started to leave me a little hesitant about the program since he asked us to provide medical care, but expected other volunteers to teach us instead of himself as a doctor showing us.

After arriving to the clinic where I would be volunteering at, I was sent to work at the nurse’s station. At my rotation, there were 2 other volunteers placed there as well who had been there for about 4 weeks. One was applying to medical schools in the United States and the other was a 3rd year medical student at a university in Ireland. Luckily, one of them spoke spanish fairly well and was able to translate for us when we interacted with both the nurses and patients.

After the other volunteers briefly taught me how to perform the basic nurses duties (blood pressure, height, weight, and temperature), I was mostly on my own. It was definitely very nerve wracking having these duties when I’d never done them before and was even more difficult considering I spoke very little of the language. I was especially confused on taking blood pressure and while I immediately should have said that I wasn’t sure what I was doing, I was embarrassed to tell the other volunteers since they insisted it was an easy task and that I’d get the hang of it eventually. This is definitely something I wish I could’ve gone back to and done differently because there is a large possibility that patients’ information was recorded incorrectly due to my lack of experience. This was when I started to realize that gaining hands on experience wasn’t what I imagined at all. In my head I thought that everything would go smoothly and I would be ready to help the professionals in anyway possible. In reality though, my lack of experience became even more apparent to myself and I started to become suspicious that the “help” I was providing wasn’t all too helpful.

Image result for antigua guatemala crossWhile my lack of training may have led to incorrect patient information being taken down, there were other pre-med volunteers who were given duties that were even further beyond their scope of understanding and led to medical complications for patients. Since there were other volunteers working at my clinic, they cautioned me right away that I shouldn’t help with procedures such as giving stitches or injections since we didn’t have the training for that (I think they figured taking down patient information was harmless enough that my inexperience wouldn’t be an issue). I was very thankful for that advice since I was already feeling uncomfortable with the duties I had, I couldn’t even imagine how stressed I would have been if I had to perform anything more advanced. However, other volunteers weren’t as reserved. I remember this one other volunteer bragging to me about how the doctor had allowed him to give injections to a patient. He said that he didn’t really know what he was doing and he ended up piercing her 5 times because he kept doing it wrong. Another volunteer told me she helped stitch a patient up and said she was concerned that her stitches weren’t done right since she had never done it before. It was at this point that I really started to question the program we were on. Why weren’t there more regulations enforced by the program? Why were the duties of the volunteers so ambiguous? Why was I starting to feel so uncomfortable with what I was doing and why weren’t the other volunteers having the same questions I was?  

Besides just the volunteer aspect of the program, there were a lot of problems with the program as a whole, in particular when it came to safety. We were warned to never travel by ourselves at night. In keeping with those rules, two volunteers on my program walked home together one night after hanging out downtown. On their way home, someone pulled a knife on them and took all their belongings. The volunteers were traumatized and felt very unsafe about what had happened and contacted the program to let them know of the situation. The program responded incredibly insensitively and told them it was their fault for walking home late at night and didn’t provide any support for the two. Their response to an emergency situation such as this really made me concerned about the legitimacy of this program. They had told us it was okay to be out at night as long as we weren’t alone, yet blamed the volunteers for what happened instead of offering emotional support and/or more information on how we could stay safer while out at night.

I left my program feeling differently than I had expected. While I loved the country I was staying in, I felt disconnected from what I was actually doing. I felt uneasy about what myself and other volunteers had done without any medical experience and questioned my helpfulness. My experience showcases how easy it is for medical volunteering programs to be problematic and harmful for the communities they’re situated in when there is not an emphasis on global health ethics.

 

Note from CFHI: Many thanks to Zoe for sharing her story. If you have questions about ethical engagement in global health experiences please visit the publications page on the CFHI website (https://www.cfhi.org/publications) or listen to a recent webinar (https://www.cfhi.org/cfhi-webinars). We are also always available to answer questions about ethical global health engagement- contact us at students@cfhi.org.

CFHI at the Forefront of Ethical Standards in Global Health Education

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As global health programs increase in popularity among students based in the Global North, an important conversation around “voluntourism” and intentionality in international health-related programs has emerged. Voluntourism often consists of students engaging in short-term volunteer work that they are not professionally, socially, or culturally equipped to take on, and – though well intentioned – often perpetuates hurtful stereotypes that low and middle-income countries need help from high-income countries. At their worst, global health voluntourism programs may offer students opportunities that end up harming patients and other community members. The pitfalls of voluntourism have been widely critiqued, including through popular satires such as the “Barbie Savior– The Doll That Saved Africa.”

How then, as an organization that promotes global health education, does CFHI make sure that our programs – as well as health-related global education programs more broadly – are ethical in theory, approach and practice? Part of the answer to that question is by getting global health organizations on the same page, ethically, and giving them the guidelines needed to run quality health education programs abroad.

CFHI Executive Director Jessica Evert, M.D. has recently co-authored two sets of internationally recognized guidelines for health-related experiences abroad which outline standards in programming that can improve global health programs for students and global partners. These guidelines shift the focus of global health programs away from hands-on clinical work (which can be dangerous and have long-lasting negative impacts for patients and visiting students) and toward cultural and contextual education of healthcare in different settings globally, as defined by local experts and community host partners. They also provide key frameworks for establishing long-term partnerships with host communities rooted principles like reciprocity, local leadership, and fair trade.

Guidelines for Undergraduate Health-Related Experiences Abroad was released by The Forum on Education Abroad, a conglomerate of US colleges and universities, organizations and foundations aimed at establishing standards of best practices in international education programs. Their newly updated set of guidelines is the first of its kind set forth by the Forum and is meant to be used along with the Standards of Good Practice for Education Abroad in order to promote ethical practices specific to health-related international education experiences.

In addition to the Forum Guidelines, Dr. Evert also recently co-authored the article “Guidelines for Responsible Short-Term Global Health Activities: Developing Common Principles” in Globalization and Health, which helps to summarize existing standards and guidelines in the field.  With the release of both sets of guidelines, Dr. Evert and colleagues focus on creating a common ground between institutions and organizations involved in global health education. With clear and concise standards of best practices in global health, organizations are given the opportunity to improve the ethical standards of their programs, and to keep the best interests of host partners and student trainees in mind.

By contributing to standards of best practice in global health education, CFHI is challenging the narrative around health-centered international experiences and pushing other global health organizations to do the same.

A BRIEF REFLECTION: CUGH 2018 ANNUAL CONFERENCE

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The definition of Global Health as a field can be traced to the 2009 Lancet article that reflects a consensus reached within a sub-set of CUGH leadership at the time.  There was an alternative definition put forth at the same CUGH meeting by a colleague from Kenya. He proposed that the definition of Global Health is a “concept fabricated by developed countries to explain what is regular practice in developing nations.”  Though an oversimplification, this perspective emphasizes a real risk in Global Health education and practice — the fabrication of a context outside our own frame of reference.
The Consortium of Universities for Global Health (CUGH) is the premiere gathering for academic institutions from the United States who are embracing the field of Global Health. As an academic field, Global Health is striving to better include institutions and colleagues from low and middle income settings, and to foster a burgeoning ‘walk the talk’ movement focused on representing “local” Global Health for health equity in our own backyards.  As I return from this year’s annual conference, I am struck by an evolution in the recognition of CFHI’s work and our growing Academic Partnerships.

Though we have long been at the forefront of conversations around ethical global health engagement, often helping to define standards in the field, Child Family Health International, (CFHI) as a non-profit “NGO,” has sometimes been perceived by faculty and academic institutions as inferior to colleges and universities.  This type of thinking has pervaded universities and has led to derogatory labels such as “ivory towers.” After more than 25 years, alas, I am happy to report an increasing recognition that CFHI’s rigor, evidence-based educational programs, and operationalization of best practices in Global Health education and partnerships deserve the admiration and respect of academia.  The conversations I am having are no longer in a spirit of convincing faculty and institutions of CFHI’s legitimacy, but rather constructive discussions about the how and the why of subtle, yet essential, nuances of quality, ethical, and transformative Global Health Education and Experiential Learning.

CFHI will continue to lead with research, constructive dialogue, and standard-setting programs. We will do so because this risk of fabrication of complex realities and global health contexts worldwide is a driving force behind our work. Gratefully, CFHI, a collaboration of community and academic-based educators from 10 countries partnering with universities to provide Global Health Education, is receiving well-deserved esteem from academia.  CFHI looks forward to continuing to strengthen our partnerships with universities to teach Global Health through mutually respectful collaborations and partnerships.

How to Engage Men to Advance Change

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“Finally, we can all be ourselves”

Peter Piot, the Director of the London School of Hygiene and Tropical Medicine, echoes these words to a Stanford University conference room consisting of 390 women and 20 men, all eager to absorb this simple, yet powerful, statement.

At the Women’s Leadership in Global Health Conference, the How to Engage Men to Advance Change panel addresses what many of us, as women, have grown to understand so well: an imbalance in power dynamics does not solely alienate women and minorities, but a lack of equity truly ostracizes and limits society as a whole. Creating equal opportunities for all genders sets the stage for a world of freedom, empowerment, gender fluidity, and empathy. It provides a world where men can express emotions as humans, rather than adhering to stringent and limiting stereotypes.

Equity presents a world where a woman can confidently write her name on a grant proposal for research funding. Currently, a woman’s name on a research grant decreases her chances of obtaining the grant by a striking 50 percent.

Contrastingly, Dr. Piot’s university ranks best in the UK for women obtaining research grants. At the London School of Hygiene and Tropical Medicine, women are actually succeeding their male colleagues in receiving grants.

What makes this university different?

Dr. Piot posits that the UK recently appointed its first female Chief Medical Officer, Dame Sally, also the founder of the National Institute of Health Research. Sally advised that all universities that wish to benefit from research funding need to show that they fully embody gender equity by 2020.

While this created panic in the country, it also enacted prompt change, which serves as an effective example of top down approaches benefiting gender equity within a short time frame.

Gary Darmstadt, Associate Dean for Maternal and Child Health at Stanford University School of Medicine, echoes Piot’s words, reflecting that men are already “giving up a lot” in a world without gender equity. By leveling opportunities for women, it provides avenues for healthy relationships, wholesome family dynamics, and more women leaders. Dr. Darmstadt reiterates that, rather than a “zero sum game,” imbalance in power itself is a loss. We have a lot to gain through women’s leadership.

How do we get there?

Steve Davis, President and CEO of PATH, believes that we need to stop taking the “easy way out” by letting comments, actions, or marginalizing words slide without correction.

Among what we read, the media, what we are exposed to, music, and the realities of day to day life, the fundamental issue is that men and women alike, don’t “call it soon enough when people cross the line.”

Taking action on a day to day basis, without underestimating transgenerational impact, will lead to a society that is mindful, intentional, and empathetic. It will create a world where all genders are valued based on the same principles.

Most importantly, it will give all people, men and women alike, the freedom to finally be their true, authentic selves.

The Power of Community, Connection and Communication

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We love hearing from CFHI Almuni about how their global health immersion experience impacted them as health providers.  This month we’re sharing the reflections of Magdalene Kuznia. Maggie   participated in the Tropical Medicine & Community-Based Care on the Coast of Mexico program in Puerto Escondido.  She’s currently a clinical nurse at Stanford University, and a graduate of the University of Michigan School of Nursing.

As a nursing student I had the opportunity to travel to Puerto Escondido with CFHI. I was looking to broaden my nursing education experience. Faculty at my school recommended that I spend a summer working with CFHI so that I can better understand community health in nursing and improve my Spanish. The other CFHI scholars on my program were two physician-assistant students, and one student applying to medical school. It was fun for me to work with other pre-health students, especially ones that were going into different fields in medicine. We each had varying levels of Spanish and knowledge of medicine, so we were all able to learn from each other.

The first few weeks we rotated at different primary care clinics or “Centros de Salud.” I was in a nearby clinic that usually had two doctors and two nurses. The nurses would triage the patients, and then the doctor would see about 10 to 20 patients for about 20 to 30 minutes. The nurses there had autonomy to decide which patients saw the doctor that day, which streamlined the process for the doctor. I loved watching how the healthcare providers interacted with their patients. Appointment time was crucial, since most patients only came in to see the doctor when something was wrong. The doctor had minimal time to provide teaching on the ailment and healthier lifestyle practices. The nurses were able to compliment the doctors sick-care with wellness counseling.

My last few weeks my colleagues and I were together in the hospital. I think some of my favorite experiences were in the labor and delivery unit. The people of Puerto Escondido do not celebrate birth in the hospital like Americans do – the unit had about 10 beds all in one line with each other. The nurses’ station faced the beds, and the doctor would come by and assess down the line which patient was ready to give birth next. There were no men allowed, and the only private room was where the patient was transported to for the actual labor part. The mother hoisted herself on the delivery table, and hoisted herself off when the baby arrived. None of the healthcare workers celebrated outwardly when a baby was born; the mother later received her baby and went on with her day. However, one man was so excited to have his first child, he snuck on to the unit to visit his wife and baby. The new parents were so excited and burst into tears of joy. The nurses allowed them to have their time together and then promptly shooed the man away to give the other patients their privacy. Their touch of excitement broke up the hustle and bustle of the day.

In nursing school, we discussed often the importance communicating on the same level as our patients. While we are educated in medical terminology, many people are not. As nurses, it is our focus to translate the medical language and apply it to our patients’ world. Puerto made this layer an important challenge for me. My Spanish skills were put to the test as I did my best to understand the common language of the people and the medical language of the health care practitioners. My Spanish going into the trip was purely conversational at best. My first weeks in Puerto I was able to physically see the affects of the disease or trauma on the patient, but later I became much better at listening to how the ailment affected the patient personally. CFHI offered us medical Spanish classes in the afternoons, which helped us piece together some of the issues we saw in the clinic or hospital earlier that day. I definitely saw an improvement in my Spanish-speaking skills by the end of the trip.

To this day, I still dream of the food that I ate and the beaches I ventured. Additionally, my time in Puerto ensured how I much loved taking care of different populations. It was a challenge taking care of people with a different language than myself. As a nurse today, I am constantly humbled by what I have to learn from others, and I am so happy my time in Puerto helped open me up to what the world can teach us.

Thoughts on Experiences in Global Health: Synthesizing perspectives from students, the literature, and global communities

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CFHI is honored to receive interns from around the world at our offices in San Francisco. This summer we have the pleasure of welcoming Alessandra Khodaverdi from the University of San Francisco. Alessandra is a Master of Public Health student who is deeply passionate about traveling and ensuring global health equity. During and after her internship, she hopes to integrate CHFI’s guiding principles of sustainability, humility, and reciprocity into her own work on community and global health disparities to build a better future for all.

Greetings! I am Alessandra Khodaverdi, an MPH student from the University of San Francisco. I am currently in my final program semester, and am finishing my current capstone project on health equity and access from the lens of undocumented migrant workers in host countries. Recently, I participated in an internship through the United Nations-mandated University of Peace in Costa Rica. This short-term experience in global health (STEGH) made such a profound impact on my life not only as a student, but also sharpened my public health lens as a professional. The first-hand knowledge and education about the integrative aspects of culture, human rights, environment, and sustainable health practices are immeasurable, and I will carry them with me forever.

Benefits and Drawbacks of Short-Term Experiences in Global Health

While high-income countries (HIC) student trainees are embarking on global health experiences in low-and middle-income countries (LMIC) in growing numbers, the perceived benefits and disadvantages for host communities are not well captured. An obvious interest and increased demand for global health education has directly expanded educational programs and STEGHs. However, despite positive intent to gain knowledge and make an impact in developing communities, such STEGHs may actually exacerbate global health inequities. “In the absence of clear definitions, standards, impact data, and appropriate conducts, STEGHs may represent a suboptimal use of time and resources, harm the host community, and even perpetuate global health inequities” [4]. Frequently, an array of ethical issues arise when trainees volunteer or are asked to perform tasks beyond their scope of training. Other factors such as  false advertisement by unreliable volunteerism programs, vague admissions criteria, and lack of program and student oversight contribute to an unethical nightmare. This is a particular problem when HIC trainees travel to under-resourced communities where patients are completely unaware that these pre-health students are not actual health professionals, despite the trappings of white coats and scrubs.

A plethora of studies have well-exemplified and highlighted the various benefits of STEGHs for student trainees. Such benefits include increases in skills and confidence, better understanding of the social determinants of health, and dedication to underserved communities back home. As supplemental studies into the underrepresented LMIC voices are desperately needed, a recent CFHI study conducted in La Paz, Bolivia and New Delhi, India revealed important insights into the perspective of LMIC host community members with regards to STEGHs. Benefits for hosts included improvements in job satisfaction, rise in local prestige of physicians and their practices, resource enhancement, and opportunities for global connectedness, leadership skills, and improved local networks and leadership development. Adversely, reported drawbacks for hosting HIC trainees were the perceived hesitancy and apathy of student trainees, unfulfilled promises, lack of cultural sensitivity and equal opportunity. Additionally, the costs of host undertakings continue to go unrecognized despite best practices outlined the Working Group on Ethics Guidelines for Global Health Training (WEIGHT). These WEIGHT guidelines outline and advise the importance of recognizing the true costs in terms of labor, time, and resources for host communities in educational student immersions. [2]

CFHI: Ensuring Reciprocity and Sustainability through Asset-Based Community Engagement and Development

CFHI was designed to prioritize strength-based partnerships, sustainable reciprocal benefits, and clear recognition of costs incurred by host communities. Being that reciprocity and sustainability are central to CFHI’s organizational approach, programs and reciprocal investments in host communities center on the asset-based community engagement/development approach.

With this model, the outsider supports community empowerment by enabling local asset mapping, organizing assets around a mutual agenda, and building consensus toward a shared development goal. The emphasis for support is placed on a community’s existing strengths and potential as the building blocks for success, rather than rewriting the entire script.

As CFHI’s motto is “Let the World Change You,” the organization highlights students as learners, rather than agents of change—as it is imperative that trainees must first understand culture, reality, and context before initiating change. As a future public health professional, these concepts of health equity and sustainability are immensely important, especially in my past work with undocumented women and migrant workers, and future endeavors with vulnerable populations. The most important point I have taken away from both internships so far is the importance of respect —especially for host marginalized communities that invite us to learn. When a mutual respect and cultural understanding is established, it paves the way for open communication, positive leadership, and a true appreciation for the complex challenges and solutions in global health.

Sources:

[1]  Cherniak, W., Latham, E., Astle, B., Anguyo, G., Beaunoir, T., Buenaventura, J.H., DeCamp, M., Diaz, K., Eichbaum, Q., Hedimbi, M., Myser, C., Nwobu, C., Standish, K., & Evert, J. (2017) Host perspectives on short-term experiences in global health: a survey. The Lancet Global Health, 5(9). DOI: http://dx.doi.org/10.1016/S2214-109X(17)30116-X

[2] Evert, J. (2015) Teaching corner: child family health international: the ethics of asset-based global health education programs. Journal of Bioethical Inquiry, 12(1), p. 63-67. DOI:10.1007/s11673-014-9600-x

[3] Kung, T.H., Richardson, E.T., Mabud, T.S., Heaney, C.A., Jones, E., & Evert, J. (2016). Host community perspectives on trainees participating in short-term experiences in global health. (2016). Medical Education, 50, p. 1122-1130. DOI: 10.1111/medu.13106

[4] Melby, M. K., Loh, L.C., Evert, J., Praterm C., Lin, H., & Khan, O.A. (2016). Beyond medical “missions” to impact-driven short-term experiences in global health: ethical principles to optimize community benefit and learner experience. Academic Medicine, 91(5). DOI:10.1097/ACM.0000000000001009