Category Archives: Rotations

Why Global Health Ethics Matter: A Personal Story

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Image result for antigua guatemala

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

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

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

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

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

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

While 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.

Seeing India Through New Eyes: An Indian-American Student’s Study Abroad Experience

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In December 2014, I left the comforts of San Francisco to take part in the Public Health & Community Medicine in India program through Child Family Health International (CFHI). During my 4 weeks in northern India, I had the opportunity to engage with and learn from various non-governmental organizations that are tackling public health challenges like injection drug use, sanitation, and prostitution. For the first week, we worked with a WHO-recognized organization in Chandigardh that focuses on women and children’s health care. One of my fondest memories from this experience was being able to interact with the female sex workers that this NGO helps. I had the opportunity to sit down and talk with Aditi*, who told me how her hardships from back home forced her to become a sex worker in order to keep her children in school. Listening to Aditi’s story really put my life into perspective. Aditi, who is a mom, sister, wife, and daughter, was literally sacrificing her own body for the sake of her children, something only a strong individual would be able to do. I couldn’t help or stop Aditi from being a sex worker, however what I could do was be someone she could talk to, someone who would listen to her, even if only for a short amount of time. It was an exchange of hellos, an exchange of respect, and an exchange of appreciation that I could give Aditi, and ironically, in the end, what she gave me. This experience taught me that it is impossible to understand a public health issue like prostitution without understanding the human beings whom it affects.

When I embarked on this experience, it had been 6 years since my last visit to India. The transformation I saw in the country was phenomenal. I noticed improvements in infrastructure and cultural changes. Years ago, the topics of HIV/AIDS or sex workers were very taboo. No one liked to acknowledge any health risks and the government wasn’t doing much to spread awareness of such issues. Visiting the country now and witnessing the many programs the government has implemented within each state was inspirational. Programs such as NACO have made such a difference in the lives of countless people across northern India by providing necessary services and supplies to lead a healthier and safer lifestyle. Apart from HIV/AIDS, I also witnessed changes in the caste system in India. In this system, “untouchables” are deemed to be the lowest caste because of their occupation of being scavengers (individuals who clean up human waste from homes due to lack of toilets). This program gave us the opportunity to work with a UN-recognized social service organization based in Delhi that is committed to getting rid of the untouchables caste by creating a toilet complex system to implement in villages across the country.

Being an Indian-American, I was able to appreciate India in a manner I never had before. I had always heard about various problems in India, whether it was about the spread of HIV/AIDS or the controversial caste system, but I always felt helpless living more than 8,000 miles away. Through CFHI, I was lucky enough to meet people like Aditi, and listen to their stories to understand what really is going on in the world outside of our own bubble in America. Often times, I have heard my very own friends and family who are Indian-American comment on how “backwards” India is in terms of development and simple progressive ideology about issues pertaining to HIV/AIDS. By experiencing India first hand, I now have the knowledge and experience to educate my friends and family and help them be more aware of important public health issues. Reading and hearing the news about India is one thing, but actually being within India’s space and engaging with the people of that country helps put these issues in perspective.

As a senior graduating college soon, I am at the crossroads where I have to choose what I want to pursue for the rest of my life. After my 4 weeks in India, I realized that this trip wasn’t coming to an end for me, it was just the beginning. CFHI not only gave me clarity, but also a sense of direction. The CFHI program solidified my decision to pursue a career in the field of public health. Prior to the program, I knew that I wanted to obtain my MPH, however I wasn’t clear on what specialty to emphasize in. This trip exposed me to the world of global health and made me realize that it would be the perfect field within public health for me. CFHI not only helped me fall in Iove with India again, but it also helped give me a sense of purpose that I perhaps would not have found without this trip.

*Name has been changed to respect privacy.

Special thanks to our guest blogger, CFHI alumna Deepa Mistry, for authoring this post.

CFHI Voices: One Northwestern Med Student’s Summer in the Himalayas

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In July of this year five students from Northwestern University’s Feinberg School of Medicine traveled to rural India as part of a unique global health program organized by Child Family Health International – CFHI, the second trip organized through their unique partnership. Funded by Northwestern’s Center for Global Health we set out to learn about public health, increase our cultural competency, and develop clinical skills by participating in a four-week clinical shadowing experience across Northwest India. We rotated in different settings, from tiny villages like Patti tucked away in the foothills of the Himalayas to the bustling city of Dehradun, in both public and private healthcare sectors. During our time in the clinics, on the wards, and in the field we witnessed healthcare disparities as they are manifested between rural and urban regions, between private and public sectors, and between different socioeconomic groups. We were able to see, for cultural and economic reasons, how differently medicine is delivered half a world away.

That month spent in India was an unforgettable and magnificent experience: the medicine we witnessed, the physicians and nurses we worked with, and the patients we got to interact with brought the kind of perspective to my medical education that only an actual, immersive experience that being abroad could bring. We didn’t stay in hostels or hotels – we lived with Indian families in their homes or in dormitories within the hospitals.

Nothing can beat that kind of immersion; nothing can beat waking up in a tiny mountain village everyday at 5:30AM with my fellow travelers to do yoga, or getting woken up in the hospital by a nurse to aid in a delivery or assist in the emergency department. We explored palaces and temples, hiked through jungles, and sampled the multitude of sights and smells, the cacophony of sounds, and the delicious and exotic foods. India brought piece and calm to my mind and body, it gave me perspective on the doctor/patient relationship, and reminded me what medicine is really about – one component of the greater endeavor to help ameliorate human suffering in the world.

India left a lasting impression – one that no doubt will shape my medical career, but also my personal life. It left me wanting to return to the more disenfranchised parts of the world to practice medicine, it left me a with a firmer perspective and appreciation of my own upbringing, and it left me with fond memories of a country I would dearly love to visit and explore again in the future.

Jason Chodakowski

Northwestern University Feinberg School of Medicine

MD Candidate – Class of 2016

Student Essays Reflect Realities and Impact of Global Health

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

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

The Power of IFMSA & The Global Health Placebo Effect

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International Federation of Medical Students’ Associations (IFMSA) is not just another acronym in a field laden with catchy abbreviations- it is a groundbreaking organization that despite its 60+ years of existence is doing something that remains innovative- bringing together medical student colleagues from around the world to work together as peers.

IFMSA Meets in U.S. for the First Time in Decades

Dr. Jessica Evert, CFHI Executive Director & IFMSA Alumna, with other IFMSA Alumni

This year the setting for the IFMSA General Assembly is Baltimore. Medical students from Sudan work alongside colleagues from the US, those from Panama collaborate with Poland, the interactions are endless. As an alumna of IFMSA I got the privilege to join the meeting and reconnect with old friends from my days as IFMSA-USA Vice President. IFMSA’s US affiliate is the American Medical Student Association (AMSA), who is also partnered with CFHI. IFMSA is a great resource for AMSA members, especially those interested in global health. Often the global health dialogue is dominated by Western voices. IFMSA allows 1,000+ medical students from around the world to work face-to-face twice a year. It democratizes global health and allows for crucial relationship development that is necessary for a unified global advocacy voice for health equity and justice. It has the secondary effect of humanizing perceptions of the developing world- rather that breading pity; it engenders mutual respect between colleagues from both resource-rich and resource-limited countries.

CFHI Global Health Approach Shared & Praised at IFMSA

Child Family Health International (CFHI) was in great company during the IFMSA alumni meeting. Attendees praised CFHI for its gold-standard model for global health education. Colleagues from Ghana, Serbia, Philippines, Nigeria, and beyond approached me with gratitude for CFHIs important advocacy voice in the global health education field.

I was equally as impressed by the candid discussion about advocacy provided by Predrag Stojicic from LeadingChange. Predrag distilled buzz words and espoused a platform for grassroots champion recruitment and leadership. A thoughtful organization, The 53^rd Week, took the stage to describe their pragmatic approach to evaluate and maximize short-term medical trips. These trips are characterized by volunteers going to resource-limited communities, usually for 1-2 weeks to deliver medical care and related services. While well intended, the global health community is increasingly leery of short-term volunteer experiences, as their impact has been questioned and downfalls revealed.

The ‘Global Health Placebo Effect’

Lawrence Loh, co-founder of The 53^rd Week, calls the appearance of impact enabled by short-term medical missions the “Global Health Placebo Effect.” Under the strong leadership of Loh and co-founder Henry Lin, The 53^rd Week is creating a platform for the multiple, disjointed teams who visit a community at different times during the year to coordinate their efforts to created continuity, sustainability, and an overarching orchestrated approach targeted towards upstream interventions. Concurrently, they are raising awareness of the risks of short-term medical missions and suggesting alternatives that may lead to more tangible and sustainable ‘help.’

The efforts of these great colleagues and the synergy with CFHI philosophical approach and model of running Global Health Education Programs has been inspirational!

CFHI Featured at AAFP Global Health Workshop

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

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

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

Global Health Training Guidebook: 2nd Edition Out

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Global Health Training in Graduate Medical Education: A Guidebook

Extra, Extra! Read all about it! Just published, the second edition of the guidebook is edited by Jack Chase, MD and CFHI’s own Medical Director, Jessica Evert, MD. The book builds upon the first edition to provide an expanded, evidence-based perspective on curriculum and capacity-building in the global health workforce.

The guidebook contains relevant material for readers at many career levels, from college and professional students to medical educators and residency and fellowship training program directors.

The 2nd edition is now available in paperback and e-book from Amazon.com, and can be read from the GHEC website.

Congrats, Dr. Evert!

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Read more about CFHI’s Global Health Education Programs that provide global health training to 700 students per year.

Students Asking Difficult Questions on Global Health Engagement and Development

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

Celebrating 20 Years of CFHI

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Happy Birthday, Child Family Health International!

2012 marks the 20th anniversary of CFHI’ s transformative Global Health Education Programs and Community Empowerment. This milestone gives us a chance to celebrate and to look back on the impact of CFHI. Continue reading →

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

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Oxford Handbook on Neuroethics

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

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

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

Read the full CFHI Press Relase and Chapter.

Empowerment Means Having a Voice

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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.

New US Census Data Shows Diversity of US Population Increasing

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

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

Source: US Census Bureau -Director's Blog

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

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

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

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

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

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

CFHI Teams Up with SNMA for Special Global Health Experience

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CFHI and SNMA have teamed up to present this new and specialized program that offers participants the opportunity to participate in a 2-week global health program in the city of Oaxaca Mexico!

The Student National Medical Association (SNMA) is the oldest and largest, student-run organization focused on the needs and concerns of medical students of color. For over 40 years SNMA has been dedicated to ensuring culturally sensitive medical education and services. For 20 years, CFHI has been offering Global Health Immersion programs designed to help students appreciate the role that culture plays in health and healthcare. By teaming up, CFHI and SNMA hope to make a Global Health experience accessible to more students. This special 2-week program, previously open only to SNMA members, is now open to all health science students. Space is limited so apply early.

The SNMA-CFHI 2-week Urban Primary Care in Oaxaca program aims to introduce students to the cultural competencies that are crucial for effective health care professionals. This program is tailored for those who wish to increase their cultural and linguistic competency as well as their understanding of the health factors affecting Latinos.

Oaxaca is an excellent setting for studying the healthcare system of Mexico and the healthcare practices of the population. Students often hold the false assumption that the healthcare is available to all, but find in Oaxaca that poor and rural populations are increasingly unable to compete for scarce health resources.

CFHI programs offer participants the opportunity to learn more about health issues that transcend national borders, class, ethnicity, and cultural divisions. By participating in CFHI’s global health education you will gain a unique insight into healthcare systems of developing countries and increase your cultural competency. Increasing one’s awareness of other cultures (cultural competency) is becoming increasingly relevant for healthcare professionals as industrialized countries become more ethnically, culturally and linguistically diverse. Click here to read an article and learn more about why cultural competency is important for today’s healthcare workforce.

The program dates are June 3^rd to June 18^th. Please visit the CFHI website to learn more.

We look forward to having you join our grassroots work to build a global community in support of better healthcare for underserved communities and more globally aware health professionals!

Global Health TV Looks at CFHI Program In India

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Global Health TV, based in London, recently visited one of CFHI’s Community Health Projects in India. The Catch Them Young Program is a health education program directed at youth ages 12-19 in a rural area outside the city of Pune. This is one example of a typical CFHI Community Health Project that originates at the local level and therefore has local ownership. CFHI has been happy to provide some of the funding to advance this project and to support the great dedication that local health professionals and community workers have to their own underserved communities.

The 5 minute short film can be seen on the Global Health TV website. We have posted it to the CFHI YouTube Channel as well. It also shows one of CFHI’s Global Health Immersion Programs in India. CFHI seeks to identify local community health professionals who are dedicated to local underserved communities.

GHTV Feature of CFHI Community Health Project Computer View

GHTV Feature of CFHI Community Health Project in India

These unsung heroes are local experts and CFHI works with them to develop the 4-12 week Global Health Immersion Programs that international students of the health professions attend. The programs are empowering to the local community as the community sees their own health professionals instructing and mentoring international students. The film had its debut at the Canadian Conference on Global Health in Ottawa, November 1-3, 2010.

CFHI Alum Reflects on Her Experience in South Africa

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Stella Chiu who spent part of her summer on one of CFHI’s Global Health Immersion Programs in South Africa contributed to a blog on the IE3 Global Internships website. Her blog post Coming Home with New Perspectives is an honest sharing of her thoughts as she is still in the re-entry process. Stella says, “I haven’t had any major problems re-integrating. However, the only difficulties I’ve encountered are through the new perspectives that I’ve gained.”

Stella reports that after being completely immersed in the South African culture and healthcare system, and especially with the warm welcome of her South African host family, she now finds herself, at times, ‘homesick’ for South Africa. Stella recommends to others who go abroad to build in time to reflect after coming home, to “sit down and think” so that you can become aware of how your perspective has changed “both personally and professionally” by what you have experienced. She says of her friends, “Sometimes it is hard for others to understand my outlook on certain things because they have not experienced what I have experienced.”

As part of her own reflection, Stella shares, “I am grateful for the opportunity CHFI-South Africa has given me in developing my clinical skills and finding my niche. I did rotations in surgery, pediatrics, ophthalmology, and in internal medicine and found an unexpected love for surgery. I grew to understand South Africa’s health care system, as well as its deficiencies, setting the groundwork for when I can return someday to work. I have built lifelong relationships with students in the program, and the families that I stayed with. I know that I will always have a home in South Africa.”

We wish Stella well as she continues her re-entry and we know that her host family and those who worked with her in South Africa were grateful for her presence and will never forget her.

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 Alum: “It Made Me Want To Be A Doctor A Lot More…”

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“It made me want to be a doctor a lot more, for sure,” she said. “Seeing doctors in action, they were really fantastic role models. It’s hard to get exposure shadowing doctors here (in the Bay Area). I’ve had a few opportunities at Stanford. The more time I got… the more inspired I am to become a doctor.” These are the words of Christina O’Neal, as reported in the Contra Costa Times by Correspondent Doug Mead. Christina, a Stanford University premedical student, spent part of her summer in the Cultural Crossroads in Health Program in Oaxaca, Mexico.

Christina told the Contra Costa Times in the article that her month on the CFHI program in Oaxaca, “was pretty life-changing. Everybody gets pretty much free health care there,” she said. “It’s interesting to see how things are run. There’s a lot of poverty, and the government, in terms of health care, has a lot of problems. But the infrastructure was good. I was impressed with how smooth it ran and how dedicated the doctors were. It was an awesome experience.”

The experience really improved Christina’s Spanish and Medical Spanish skills. “I’d say, before I got there, I was conversational (in Spanish),” she said. “Now, I’m borderline fluent. My comprehension, especially, skyrocketed. I’ve always had a pretty standard ability to speak. Now, I understand everything that’s happening. Even though my vocabulary didn’t grow as much, I can express myself better. Once you understand people better, it helps you to speak more correctly. We went over grammar and medical vocabulary every day (in class).”

We are very glad for Christina that her experience was so impactful and we greatly appreciate her kind words about the CFHI program as she ended her interview with the newspaper saying, “Everything was fantastic. It surpassed all my expectations. It was a phenomenal experience.”

CFHI Students make Local Press in Ecuador

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CFHI students made the local press in Ecuador this summer. La Prensa, a local publication in the town of Puyo in the Pastaza Province of Southern Ecuador, carried a full page story of CFHI Students on the Amazon Indigenous Health Program, one of CFHI’s Global Health Immersion Programs.

CFHI Students Make New in Ecuador Summer 2010

Puyo, a city of about 25,000 people, with its close proximity to the Amazon Jungle, functions as the base for this program that allows students to see the interplay between the government Ministry of Health and the traditional medicine of indigenous populations living in the jungle much as they have for many hundreds of years. Dr. Wilfrido Torres, a local physician and the Medical Director of several CFHI programs, reports that international students coming to Puyo and to the Jungle Region, “help the local population see that local doctors and community health workers have important knowledge to share with the world.” CFHI is honored to have local experts like Dr. Torres who are eager to interact with international students.

This summer, the CFHI students were able to participate in a medical conference that CFHI helped support. The conference, a multidisciplinary conference on the latest treatments and testing for diabetes and hypertension, was part of a series of conferences to educate health professionals and paraprofessionals on these chronic diseases that are relatively new to the local population.

University of Oregon Students Receive Awards for CFHI Programs in Bolivia and South Africa

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Ann Oluloro and Stella Chiu, both students at the University of Oregon have received scholarships awarded by the IE3 Global Internships Program. Many other students from participating IE3 Schools will attend CFHI programs this year and will receive credit from their home institutions. Oluloro and Chiu, “…stood out among their peers…” according to the IE3 Field Blog Website.

Ann Oluloro Bound for Bolivia

Ann Oluloro will be participating in CFHI programs in Bolivia starting in July 2010. In her CFHI application she identified several reasons for seeking entrance to a CFHI program in Bolivia. Becoming a fluent Spanish speaker is important for her professional goals. “Being fluent in Spanish is an important part of my future career because I plan on working in public clinics. Currently, as a volunteer at White Bird Community Clinic, I often see the doctor communicate with patients in Spanish. By being able to speak another language, the doctor is able to break down a communication barrier that would have otherwise existed and is therefore able to provide the patient with the best care she possible can.” She dreams one day of working with Doctors Without Borders and she believes that her CFHI experience, “…will give me a deeper insight into international medicine…” and help her “…learn about a culture and a way of life that books and textbooks cannot provide.” She hopes that her time in Bolivia, “…will give me a glimpse and understanding of a culture that I may otherwise not have a chance to learn about first hand. In addition, the internship will teach me about the structure of public health systems and how such systems are implemented in under developed nations both in rural and urban settings. Ann has done her homework, reading about the challenges faced by many countries to provide healthcare to their populations. “I am highly interested in how some under developed nations are still able to find ways and means in which to implement effective public health systems.”

Stella Chiu will be participating in CFHI programs in South Africa. Stella’s goal is to become a doctor and also to have an impact on underserved populations. She sees being part of a CFHI program as, “…a perfect match for what I want to do with my future. I want to become a physician and gain clinical experience, but I also want to help underdeveloped countries with public health efforts.” For Stella, it is important to be immersed in another culture, “I hope to gain clinical experience in a setting that is different from that of the United States. I believe this would make me a better physician in the future because it will help me see beyond the privileged population and be more competent in serving the less privileged. I hope CFHI will provide me with opportunities to learn and experience things first-hand.”

Both Ann and Stella will be reporting on their experiences so we look forward to more in their own words. We wish these students well as they embark on a summer that they will surely remember forever, and good luck with the tremendous potential of career opportunities that await them in the future.