Category Archives: Ethics

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

Oxford Handbook on Neuroethics

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

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

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

Read the full CFHI Press Relase and Chapter.

World Food Day

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World Food Day

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

Past Successes Have Not Kept Pace

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

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

FAO Food Price Index October 2011

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

Promising New Successes

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

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

Empowerment Means Having a Voice

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Voices of empowerment from women in rural Northern India

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

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

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

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

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

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

A Visit with The Father of Palliative Care in India

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

Pallium India

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

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

Who is Dr. Rajagopal

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

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

A Day in the Life– Implementing Palliative Care in India

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

Ms. Hema and Dr. Raj on home visits

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

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

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

Dr. Raj conducting a home visit, Trivandrum Southern India

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

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

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

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Ukwanda Logo

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

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

Avain Park Old Clinic

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

Freight container being prepared at Cape Town Water Front

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

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

Avian Park New Clinic 2011

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

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

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

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

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

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

CFHI Joins in Support of Service World

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CFHI is very excited to support the launch of OurServiceWorld.org and the ServiceWorld International Service Declaration. Those of us involved in Global Health are deeply committed to international service. The ServiceWorld Initiative is an effort to commemorate the 50th anniversary of the Peace Corps by realizing President Kennedy’s original vision of sending 100,000 volunteers to serve abroad each year. Please join us in supporting the future of international service by signing the ServiceWorld International Service Declaration and endorsing ServiceWorld.

As a proud member of the Building Bridges Coalition and the International Volunteer Programs Association, CFHI is happy to join a groundswell of international organizations in support of this effort. Please join with us.

CFHI Convenes UN Forum on MDG 3 Empowerment of Women

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Earlier this month on September 15, 2010, CFHI convened a Forum on the Empowerment of Women, at the United Nations in New York. The purpose of the event was to increase awareness of the United Nations Millennium Development Goal #3, to Promote Gender Equality and Empower Women.

Ambassador Anwarul K. Chowdhury, former Under-Secretary General and High Representative for the Least Developed Countries, moderated a panel of women representing a cross section of leadership roles. As world leaders met this past week to discuss the MDGs, this Forum, held a week in advance, provided an opportunity for the voices of women from everyday life t be heard. Co-sponsoring NGOs included the NGO Committee on Spirituality, Values and Global Concerns, The International Center for Good Business, The Institute of International Social Development, and The Spiritual United Nations. Panelists included M. Christine MacMillan, Commissioner, Director of the International Social Justice Commission of the Salvation Army, Monika Mitchell, Executive Director, Good Business International, Hema Pandey, India Coordinator, Child Family Health International, and Jessica Evert, MD, Medical Director, Child Family Health International.

The Title of the Forum was Successes and Challenges of Women in Leadership Roles in Traditionally Male-Dominated Environments. As women are increasingly taking on leadership roles, it becomes important for them to share their experience. The panelists spoke with examples from their own lives and the audience was invited to share their comments and life experience as well.

We were especially happy to welcome our India Coordinator, Ms. Hema Pandey who was visiting from New Delhi. Hema is responsible for coordinating six CFHI Global Health Immersion Programs taking place in Mumbai, Pune, Delhi, Dehradun, and Rishikesh, as well as multiple ongoing community health projects. In the course of this work, she manages a group of five local CFHI Medical Directors, all of whom are men. Ms. Pandey spoke of using a cooperative style of working that invites the participation of those she works with thus creating a joint feeling of ownership. This being her first trip outside of India, Ms Pandey said she was surprised to find that women in the United States also felt that they were still struggling to achieve gender equality.

As the Forum drew to a close, there was a common expression of the panelists and the audience that this Forum should become and annual event until 2015, the target year for the Millennium Development Goals.

CFHI Medical Director Blogs on Day 2 of CUGH Conference

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This is the second of two guest blogs by Jessica Evert, MD, CFHI Medical Director, blogging from the CUGH Annual Meeting in Seattle. Be sure to leave a comment.

Ann Dower of University of Washington’s I-TECH Center said today “we must practice the art of partnership” in order to be successful in global health. Additionally, I was struck when Kevin De Cock MD, Director of the Center for Global Health at CDC, candidly reflected on his early career immersion experience in Nairobi, Kenya, saying, “I wish I was more humble.” I think this humility and the ability to form meaningful partnerships go hand-in-hand.

This idea of ‘partnership’ has come up countless times at the CUGH meeting over the last 2 days. Many seasoned global health experts have lamented over the lack of partnerships and failures of global health attempts due to this shortcoming. How can we learn from this history? How can we build training and educational programs that prioritize partnership? It seems that many times our process (the process of US based individuals, universities, and organizations) of global engagement is not necessarily the best approach to foster partnership or humility. We often have our own ideas of how to solve problems based on our views and our skills, rather than based on the voice of communities abroad. In academia, there is the nagging issue of faculty, and sometimes students, having to demonstrate personal accomplishments and quick outcomes which often trump the empowerment of communities to own the accomplishments and guide the outcomes. To find the answer to these important questions we need to look at how we frame introductory global health experiences for health science trainees (pre-health, medical, nursing, public health, allied health, dental, and other students) and how our academic institutions approach global engagement. The first experience abroad (a stepping stone experience) or first visit to a region or country is pivotal to frame how future global engagement occurs. If individuals go abroad and set-up a tent clinic outside the local healthcare infrastructure, an appreciation for local capacity, systems, and workforce is not realized. If students go to a hospital with faculty from their US institution who displace local physicians and assumes US clinical expertise translates immediately into similar expertise in an international setting, the student sees the glorification of US faculty, rather than the appreciation of unique practices, language, and expertise of local, native practitioners. It is time we recognize that the skills necessary for partnership need to be fostered from early levels of engagement and need to be modeled by our US teaching institutions and mentors.

How do we teach health science students and trainees about partnerships? What skills does partnership require? To delve into these questions, we must define partnership. The Partnering Initiative, an NGO that specializes in partnership training, defines partnership as follows: “a cross-sector collaboration in which organisations work together in a transparent, equitable and mutually beneficial way towards a sustainable development goal and where those defined as partners agree to commit resources and share the risks as well as the benefits associated with the partnership.” This is no simple task. They also define the partnering principles as follows- equity, transparency, mutual benefit. If partnership is fundamental to the success of global health activities, then we must judge global health activities in part based on these fundamental principles. The need for trust, mutual respect, and communication are presupposed in the process of building partnerships.

We can teach the principles and precursors to partnership through thoughtful global health immersion programs. I am proud to be a part of CFHI. I think CFHI is setting a standard for both academic and NGO based immersion programs. I liken CFHI immersion programs to participant-observation techniques I utilized during my thesis work. In anthropology the mechanism of understanding a culture, community, and executing research is participant-observation. Participant observation involves gaining an understanding of another social group or community, by inserting yourself into that community in a way that is agreeable to the community, while observing the practices and learning about the culture, social structure, systems, and other behaviors. CFHI immersion experiences provide an opportunity for participant-observation. I would argue that such participant-observation, done in the context of long-term CFHI partnerships, lay the groundwork and start fostering skills necessary to form meaningful partnerships with individuals and organizations abroad. The local health care providers are the experts who teach CFHI participants what their communities are facing. We have received feedback from partners that patients consider their local providers more capable because they are teaching western health science students (rather than Western physicians or students providing the expertise in patient care at the international setting). This dynamic is very important and very powerful. The first step in the cycle of partnership, as defined by The Partnering Institute, is “scoping.” In essence we are teaching our students and trainees how to scope, which includes listening, observing, and appreciating a local reality before trying to change it.

If partnerships are key to the success of global health programs and interventions, it is time we look at what it takes to impart the skills necessary to foster partnerships. These skills include observation, humility, and restraint so we can give voice to the local community and engage in truly mutually beneficial ways. By providing stepping stone global health immersion programs that prioritize the “scoping” necessary to form partnerships, we can engender a new generation of globally-active professionals who understand from early in their exposure and interaction with global communities the fundamentals of partnership and humility that Dr. De Cook and others wish they knew from the start. It reminds me of a quote by Nietzche, “When one has finished building one’s house, one suddenly realizes that in the process one has learned something that one really needed to know in the worst way – before one began.” We can provide these lessons before students build their proverbial global health houses through conscientious global health immersion.

CFHI Convenes Forum on the Empowerment of Women

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CFHI is proud to convene a Forum on the Empowerment of Women to be held at the United Nations Church Center on September 15, 2010, in conjunction with the opening of the 65^th Session of the United Nations General Assembly.

The Forum, entitled Successes and Challenges of Women in Leadership Roles in Traditionally Male-Dominated Environments, is an effort to shed light on the global effort to achieve Millennium Development Goal Number Three.

In government and NGO organizations worldwide, women are increasingly taking on leadership roles. What are women finding as they assume these roles? From the grassroots level to the executive level, women are succeeding in roles heretofore held only by men. Are there common experiences across these different levels? Are there common challenges? What cultural issues need to be considered? What strategies are most successful?

Join the audience along with a distinguished panel including CFHI Medical Director, Jessica Evert, MD, and direct from New Delhi, CFHI India Coordinator, Hema Pandey, as these topics and others are discussed in this lively forum. Gain insights and share your own story. Join us September 15^th at 1:00 PM at 777 UN Plaza (44th Street between 1st and 2nd Avenues) 8^th floor, Boss Room. The forum is free and open to the general public but we do ask that you RSVP. Please click here to see more information here and the email address to RSVP.

Global Health Down Under -A students’ Conference- Hobart, Tasmania

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Australia site of Global Health Conference

CFHI is very happy to be at the Global Health Conference in Hobart, Tasmania that is being put on by the Australian Medical Students’ Association (AMSA). The conference running 1-4 July has a full academic program with impressive topics and excellent speakers. The entire conference is organized by and for students and the level of professionalism is truly outstanding. CFHI is very happy to be an NGO sponsor here and we find the interest and engagement of the students to be at a very high level. A CFHI alum from Perth, Samantha Mulholland (2009, Pediatric Health, La Paz), has been present and giving her first-hand descriptions of her CFHI experience.

UTAS Site of Global Health Conference Tasmania

The University of Tasmania in Hobart is the site for the conference as some 500 students gather from across Australia and New Zealand, and even from Asia and Africa.

Indeed students all over the world have a growing interest in Global Health. What is refreshing here is that so many of them are deeply informed on world issues, social determinants of health and many other areas. Panels of leading experts, student questions and discussions have all been engaging and enlightening.

Panel discussion at the Global Health Conference Hobart Tasmania July 2010

Expectations –When Helping is Complicated

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Kim McLennan, an accomplished physical therapist, and long-time CFHI volunteer, is now in Haiti and has been communicating to us some of the complexities of just trying to help. A veteran of many humanitarian missions, Kim knows that to lend a helping hand is not always as easy as it looks on the surface. The crisis in Haiti, and the

Some of the many peopel who have volunteered their time going to Haiti in the aftermath of the 7.1 earthquake

This is a U.S. Navy photo of some of the many vounteers who have gone to Haiti to help after the great earthquake

outpouring of volunteers to give assistance has amplified the Grey Areas of coordinating and managing international aid. The questions of culture, ethics, passion, compassion, and the realities of unexpected complexities are raised in her moving, first-hand account. Dr. Evaleen Jones, CFHI’s Founder and President, asked Kim if we could share her writings through this Blog. Kim gives us her experience alongside her on-the-spot reflections which are informed by her years of cross-cultural work in some very challenging situations.

We are grateful to Kim for her permission to present her observations and thoughts here. Unfinished and raw, they give us an unvarnished view of reality with no easy answers –much as the real situations in Haiti, and elsewhere in the world. You are welcome to click on the “Read More” button to leave a comment.

“Expectations

Here in Haiti, 5 months after the devastation of a 7.1 earthquake, volunteers are coming in droves. I am one of them. By the end of my stay, I will have been here 7 weeks. Most of my fellow volunteers come for one week or two if they’re lucky. Professionally, the greatest number are doctors, nurses, emergency room specialists, pediatric and wound care specialists, prosthetists and physical therapists. The majority have never been to a developing country or to Haiti before they arrive.

They come with the expectation of being welcomed for their concern and service, everyone paying their own expenses and hoping their week of selflessness will do some lasting good. Most leave, probably feeling that their mission was accomplished, even if in some small isolated way. This morning, at the hospital I’m working in, there are 20 American doctors, nurses and other hopeful people wanting to do something useful. They’re surprised when they realize how different the system is here, how charts and notes and procedures that are standard in the US are hardly used here. They are surprised that the Haitian nurses don’t speak English or seem happy to share their small desk or coveted stash of medical supplies. Many come with their own supplies of state of the art medical technology and toys and blankets and shoes. Most of it is very useful and appreciated by the patients. The Haitian staff seems to disappear when the volunteers arrive to see the rare and unusual patient injuries that have occurred here.

There have been many surgeries and interventions that would have never occurred without the volunteers being here. External fixators and wound vacs are found throughout the hospital, and the meticulous care given to the patient’s wounds is without parallel. But this is precisely the problem. The nurses here do not have the training to change the dressings or change the wound vacs and no one is training them. There will be no physical therapy or discharge planning when the NGOs pull out for good. For all their good intentions, the volunteers seem to ‘take over’ when they arrive and then complain that the Haitian staff doesn’t seem interested. Cultural differences aside, who likes it when someone new arrives on the scene, walks in, starts to do your job and then leaves, making you feel less than adequate after witnessing such expertise.

As you know, this is a touchy subject. Everyone who comes here has the best intentions, simply wanting to help. The problem is when they come, they come in groups with their own comfortable systems in place, just in a new setting. Most of the Haitian hospitals are not equipped to house or feed these additional visitors and the plumbing in Haiti already is barely serviceable. They often don’t seem to try to learn a few words of Creole, or go outside the compound to meet the Haitians and share a local meal. It probably feels like a vacation except that the food is scarce and the air-conditioning doesn’t work.

The first time I went overseas to volunteer 12 years ago in South Africa, I stayed for one month and it took me almost three weeks to feel I was accepted a little by the local staff and they still did not seem keen to have me in their midst. I have been looking ever since for better ways to interact and contribute to poor people in need of basic healthcare. I believe the answer is recognizing the potential of the local people….

It truly does no good to ‘do your thing” as a volunteer, no matter how much it is needed if you don’t teach someone else how to do it also. Volunteering in Haiti can contribute to the Haitian infrastructure only if we volunteers think about the consequences of us being here. Are we willing to be patient and work alongside someone whose future may improve from our training? Are we willing to trust that they may know a better way than the way we’ve been taught? We are influencing an entire system by our presence and we should be including them every step of the way…..”

Interview with CFHI’s Medical Director –Audio Post

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I had the chance to sit down with CFHI’s Medical Director, Dr. Jessica Evert, at our offices in San Francisco, just before she was honored with an award from the Global Heath Education Consortium (GHEC) at their annual conference in Cuernavaca, Mexico. Dr. Evert began her role as CFHI Medical Director in January. Her education career includes studies at Emory University, The Ohio State University College of Medicine, and the University of California at San Francisco, where she continues to serve as a clinical faculty member of the Department of Family and Community Medicine.

We spoke about her introduction to Global Health, how she integrates her work as a physician in the San Francisco Bay Area with her Global Health Activities, and what attracted her to CFHI. She talks about how CFHI’s model is one that changes the dynamic by empowering local communities through actively building on their strengths in ways that lead to sustainable solutions.

Please click on the links to listen to our conversation and you are invited to join the conversation through adding your comments below.

CFHI Makes List of Trusted Charities in National Press

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The Editors of the national newspaper, USA TODAY added a special section to the paper on April 13, 2010, devoted to how people can help and give to others in need. One full page of the section contained a list of the only charities in the United States that meet the highest requirements of the Better Business Bureau of Nonprofits.

CFHI listed as Trusted Charity in USA TODAY

CFHI is very happy and proud, once again, to make this list. This is the third consecutive time that CFHI has made the list and we extend congratulations to all the members of the CFHI global family for this important achievement.

Under the banner headline “Start With Trust” came the list of Seal Holders of the Wise Giving Alliance, a group of nonprofit organizations in the United States that meet all 20 of the best practice standards set by the Better Business Bureau for nonprofits. These are rigorous standards that cover areas like governance, effectiveness, finances, and fund-raising. CFHI has worked very hard to meet and maintain these standards.

CFHI Medical Director Receives Special Award -Final Report From Curenavaca

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Dr. Jessica Evert, the Medical Director of Child Family Health International, received the Christopher Krogh Award at the GHEC – INSP Conference today.

Dr Jessica Evert Receiving Special Award at Global Health Conference in Mexico

Dr Jessica Evert Receiving Special Award from Dr Anvar Velji GHEC Co-Founder and Dr Richard Deckelbaum GHEC President at Global Health Conference in Mexico

The award, honoring the memory of Dr. Krogh, a founding member of GHEC, who died in 1994 in a plane crash while traveling as a physician for the Indian Heath Service, is given to an individual who shows dedication to serving the undersered both domestically and internationally.

Dr. Evert has worked in various places around the world, and also works on a daily basis treating patients in several underserved communities in the San Francisco Bay Area. Prior to becoming the organization’s global Medical Director, she volunteered with CFHI for several years so we are well aware of her talents and her dedication. CFHI extends a hearty congratulations to our new Medical Director as she receives this distinguished honor!

South-South Collaboration

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The 19th Annual GHEC Conference and the 1st Latin American and Caribbean Conference on Global Helath

GHEC - INSP Conference 2010 Cuerenavaca, Mexico

Of course, the planning for a conference like this happens more than a year in advance so as we are gathered comfortably here in Curenavaca, Mexico, having important discussions and sharing of ideas, it is important to look back and see all that has happened along the way on the journey to Cuernavaca. Not long after the decision to have the conference, came the outbreak of H1N1 in 2009 and many questioned the wisdom of continuing with the conference plan especially with the fear that a repeat flu outbreak could happen in early 2010.

More fundamentally, the intention of this conference –different, I think, from other South-South conferences– is to have the South participants truly take the lead. “The idea from the beginning was that the North participants are the guests and are primarily coming to learn” said Karen Lam, the Global Health Education Consortium (GHEC) Program Manager. With its almost 20 year history and strong following, GHEC has been able to bring the numbers that frankly support the undertaking of a major conference like this and make it financially feasible. The back story is all the effort to truly make it a success. GHEC has partnered with the Instutio Nacional de Salud Publica (INSP) here in Cuernavaca. INSP is the conference venue and has been a great host for this event. Both INSP and GHEC are to be highly commended for all the hard work to bring this event to a reality and in such a successful way!

“The vast majority of the presentations are by and from the perspective of the South participants,” Lam pointed out. Sessions are covering everything from Ethics and Equity Issues, to Global Health Diplomacy, to Public Policy, and Social Determinants of Health.

It is encouraging to see so many Mexican, Caribbean, and South American students able to be a part of this conference and to see the work of the collaborations of their fellow students and teachers so prominently featured. So far the sharing and exchange of ideas is stimulating and leaves one hopeful for all the collaborations that will now have their beginnings here in Cuernavaca.

The Roots in Grassroots -Ukwanda Rural Health Program

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Ukwanda is a Xhosa word meaning to grow and develop. It is also the name of a rural health project run from the Tygerberg Medical Campus of Stellenbosch University in Cape Town. CFHI, with a generous grant from the Dickler Family Foundation, has helped to fund part of this project to bring more healthcare to Avian Park, an underserved community near Woster in the rural area well north of Cape Town.

Long story short, they are building on the success of a TB clinic, which was the only healthcare in this community. Once people saw their neighbors responding to TB treatment, the numbers of patients willing to come for treatment began to climb. Now they are increasing visits to homes in the community and beginning distribution of antiretroviral medication (ARVs) for the treatment of HIV/AIDS. The hope is to add more regular visits by a doctor and bring primary care to this community.

While it is still a work in progress and well on its way to success, the story behind the story is fascinating. Stellenbosch University was a bastion of Apartheid. Among its graduates are a number of the country’s prime ministers during the Apartheid regime. It still has a majority white student population but the diversity of its student body is increasing. Even for years after the change to majority rule, to think that Stellenbosch University would be successful leading an initiative to build strong relationships with multiracial rural communities would simply not have made any sense. It is wonderful to see the progress that has been made here. The university has hired a diverse team and has supported their efforts to build the relationships necessary for successful collaboration at the grassroots level. Working to earn the support of the local Rotary Club, local politicians, community leaders, and even seeking out the strongest voices block to block, the university has committed its time, talent, and funding to truly engage the community.

I met with Lindsay Meyer, who is coordinating the community engagement on this project for the university, and it is easy to see that her heart and soul are completely committed to its success. By building the support that she has, she managed to find the creative solutions when road block after road block surfaced along the way. She has taken her guidance from the leadership of the university as all the resources of the university have been made available to this project. From agriculture, to education to law and even theater, the various parts of the university have had a hand in this project. The process of acquiring land for the project has been assisted by the legal faculty; the soil was tested and found suitable for a community garden by the agriculture faculty and students; education programs have been set up and educational storytelling through drama has engaged the community even more.

Lindsay sees her work as cutting edge and it truly is. We congratulate Lindsay, her team and Stellenbosch University for doing what it takes to make this project a real part of the community and not just a satellite office of the university.

Learning From South-South Collaboration, April 2010, Cuernavaca, Mexico

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Alliances for Global Health Education: Learning from South-South Collaboration, has been announced as the theme for an upcoming conference to be held April 9-11, 2010, in Cuernavaca, Mexico. The joint collaboration represents the 19th annual conference on Global Health Issues for the Global Health Education Consortium (GHEC), based in the United States and the 1st Latin American and Caribbean Conference on Global Health hosted by the Instituto Nacional de Salud Publica (INSP), based in Mexico.

A White Paper and call for abstracts can be found on the GHEC website here.

This promises to be an exciting conference addressing current issues and even leading edge ideas, research, and practice. The Call for Abstracts is through November 1, 2009. The website reports that all aspects of Global Health and Global Health Education are welcome for submission and there is a special request for “progressively-minded projects that take into consideration the ideals of global health that embrace: Social Justice, Ethical Practices, Community Ownership, Equity and Fairness, True Partnership, and Bilateral Exchange.”

Just What Global Health Needs … Geometry!

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As Dr. Calvin Wilson began his plenary presentation at the Sixth Annual Family Medicine Global Health Workshop in Denver earlier this month, he said to the audience of physicians, “Now class today we’re going to learn geometry.” As he began talking about the vertical approach, and the horizontal approach, Dr Wilson was joking but he was also making a point. As disparities related to health continue to be significant and much more is needed to be accomplished in order to achieve the Millennium Development Goals set by the United Nations, it is clear that a different approach is needed to address global health issues. Dr. Wilson, an associate professor of family medicine at the University of Colorado School of Medicine, and the director of the Center for Global Health of the Colorado School of Public Health, was attempting to deal with a controversial issue in global health today: the debate between vertical and horizontal funding of health initiatives. The vertical initiatives are programs that address a single area of focus, such as a disease like HIV/AIDS, or malaria. The horizontal initiatives are programs that attempt to improve aspects of the health care system in an area or a country. Dr. Wilson gave a careful and balanced approach to this issue and pointed out pluses and minuses to both sides. His presentation can be found through the website of the American Academy of Family Physicians.

Dr. Julio Frenk, the Dean of Harvard’s School of Public Health, and former Minister of Health for Mexico used examples from his home country to illustrate the importance of the diagonal approach when he was interviewed in the June issue of Global Pulse. Dr. Frenk sights, how work on HIV/AIDS in Mexico was designed to also enhance the healthcare system. “By starting with AIDS, we were able to build an entire insurance system that was then in place to start covering other diseases.” Dr. Frenk’s interview with Global Pulse can be found here

It is unfortunate that this debate has gone on for so long and that there is still no clear resolution to it. Perhaps two next steps are helpful in this process.

Cease the Competition: It is sad that any debate has developed regarding this issue at all. Even more counterproductive is that at times there seems to be a competitive nature to the debate from one side or another. From the grassroots perspective, it is often obvious that these approaches are much more in concert with each other rather than in competition. Resources are needed for programs that implement specific treatments and for specific prevention methods but these programs are usually only as good as the infrastructure available to make things happen on the ground. The reality is that vertical strategies will, at some point, need to hit the ground and their implementation will involve: public health education, vaccination, or training to increase the competencies of treating healthcare workers. To utilize the existing infrastructure, no matter how lacking it might be, is preferable to starting from scratch or to creating parallel infrastructures. Building on the existing infrastructure allows the lessons of past implementation experiences to inform the future and, if done well, allows for culturally appropriate adaptations to be made for each setting that can improve the effectiveness of any implementation, while reducing the potential for inflicting unintended harm. In most resource-poor settings, when you bring in relatively small amounts of cash, you can make many things happen. Unfortunately when you pull out the cash, it often has the effect of inhibiting the local input.
A workable Construct: While there has been a lot of talk about the need for a more balanced approach, there has not been a lot of action. It is hard to move forward without a method of implementation. Since we are talking about a very broad spectrum of health initiatives, it is unrealistic, and frankly not very helpful to propose anything that is too specific. One option has been proposed that appears very promising. 15 by 2015 is an initiative proposed by a partnership of the World Organization of Family Doctors (WONCA), Global Health through Education, Training and Service (GHETS), and the European Forum for Primary Care (EFPC). In an article published in the British Journal of General Practice in January, 2008, they make their proposal, “We propose that by 2015, 15% of the budgets of vertical disease-oriented programmes be invested in strengthening well-coordinated, integrated local primary healthcare systems and that this percentage would increase over time. 15 By 2015 is a very helpful construct. It raises the awareness of the need for both vertical and horizontal approaches that complement each other and creates a simple framework that allows customization as needed. The 15% threshold is not meant to be the highest possible for the horizontal component but it is a conservative number that can surely be an agreed upon minimum. In this way, new initiatives can build on the existing knowledge and experience, and leave the community with an incrementally improved infrastructure.

In his address to the Global Health Workshop in Denver, Dr. Wilson used some different language. Instead of consistently using “vertical” and “horizontal,” he used the terms disease focus approach and integrated systems approach. These are terms that seem to fit more logically to the conversation. Perhaps these terms can be seen to be more obviously collaborative than their geometric versions and help us bridge the gap by taking the shortest distance between these two points that should not be divergent at all.

A Definition of Global Health

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Defining global health has been a challenge. This has been especially true in recent years with the increased interest in science, philanthropy, and politics related to global health. In the June 6, 2009 issue of The Lancet, a multidisciplinary and international panel brought together by the Consortium of Universities for Global Health (CUGH), and led by Jeffrey P. Koplan, MD, has taken a bold step in offering the world a definition.

The article entitled Towards a Common Definition of Global Health, represents an important step in bringing together the work, “and priorities for action between physicians, researchers, funders, the media, and the general public.” A thoughtful process is outlined considering the origins of global health in the areas of public health and international health.

The attempt is to be broad rather than limiting, and emphasizes multidisciplinary approaches and mutuality, as well as equity and collaboration.

We applaud CUGH for this effort and recommend this article to all CFHI students. We greatly appreciate that an effort has been made across continents and cultures to find common ground for the advancement of the study and the work of Global Health.

In recent years, at conference after conference, speakers have noted that there is no real agreement on just what is involved in Global Health. This long-awaited work is welcome, especially in its tone –it is not forceful or proprietary but open, inviting, and humble. We hope that it serves as a good starting point for people from all aspects of Global Health to find a workable construct that will be helpful to collaboration in our work and research.

Please go the The Lancet website and find the article.

Equity Should Play a Role in Measuring Global Health

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WHO Director-General, Margaret Chan, called for greater equity in health to be considered as part of how we measure progress as a global community.

“Greater equity in the health status of populations, within and between countries, should be regarded as a key measure of how we, as a civilized society, are making progress,” Dr. Chan said speaking at UN Headquarters in New York.

At the very least, we should all recognize that Dr Chan has a perspective that almost no one else shares. In her role as Director-General, she has been very active in discovering and learning as much as she can from all corners of the world. So when she stands before the world’s ambassadors and says, “The world is in such a great big mess,” it is the considered opinion of the world’s doctor. Of course she was trying to speak in a way that cuts through ceremony and can be easily understood by all.

She went on to give more of her considered opinion, “Pandemic influenza, for example, will hit hardest in developing countries, which have large vulnerable populations. With their weak health systems, these struggling countries will take longer to recover. In many ways, developing countries facing the pandemic are virtually empty-handed,” said Dr Chan.

With calls for systemic change being a big part of recent United Nations discussions, Dr. Chan took the opportunity to advocate for health with the assembled global leadership, “We hear clear calls, from leaders around the world, to give the international systems a moral dimension,” said Dr Chan, “to redesign them to respond to social values and concerns… A focus on health as a worthy pursuit for its own sake is the surest route to the moral dimension, the surest route to a value system that puts the welfare of humanity at its heart. Greater equity in the health status of populations, within and between countries, should be regarded as key measure of how we, as a civilized society, are making progress.”
As noted with her remarks on the WHO website, “One method for achieving fairness, she suggested, would be for more countries to embrace primary health care. As she noted, a primary health care approach introduces greater fairness as well as efficiency, and allows health systems to reach their potential as cohesive, stabilizing social institutions.”

At the Global Health Council conference in Washington, DC, in June of 2008, on Primary Health Care, a discussion involving Dr. Chan at a public session included the notion of conducting a health systems impact study when any significant funding is allocated. Typically large amounts of funding from governments, world bodies or foundations focus on a particular disease or health issue. Too often, in the heroic attempt to eradicate a menacing problem, the impact on, or even the essential contribution of the existing health system and the health workforce are considered only tangentially or perhaps not at all.

The analogy was to an environmental impact report that is often required before any large-scale building or infrastructure projects are conducted. While environmental impact reports have their own problems, the notion of considering all aspects of the health system in a community or a country can be an important way to find the strengths and successes that will be critical to the success of new efforts. Building on the local strengths and knowledge of a community and allowing a new idea to be informed by the local cultural wisdom can go a long way to achieving greater equity, including Primary Health Care in the process, and ultimately more efficient progress.