Author Archives: Robin Young

The LGBTQ+ Population in Uganda

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

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

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

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

“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

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

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