David Liskey (in a photo by Jan Sonnenmair), was a 2008 CFHI South Africa participant that came to us through our Oregon partner IE3.
David Liskey photo by Jan Sonnenmair
David was featured recently in the Oregon State University President’s report. Read about his experience and “how race, culture and poverty affect health care in a country with one of the highest HIV infection rate in the world.”
David participated in an 11 week program with CFHI and received credit from his home institution. From his first-hand experience, he wrote a University Honors College senior thesis. David was perceptive and able to see how culture impacts health.
In the president’s report, he reflects, “The different experiences and topics I studied had an effect on how I see the world.”
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.
Dr. Ebrahim Khan is a family practitioner with a private practice in the Kwazulu-Natal Province of South Africa and serves as Medical Director of the CFHI program based out of Durban. As with most doctors in South Africa, the demands on his time are great. Dr. Khan’s daily schedule is easily enough for two or three men. His long and distinguished career has earned him the respect and confidence of the local community, and even at this point in his career, his desire to be of service and give back is as vibrant as I have seen in twenty-year-old students, so he is a good match for the many CFHI students from around the world who choose the Durban program. I especially sensed a love for teaching medicine in a way that guides the students to make their own discoveries.
Among the many hats Dr. Khan wears is that of being the Vice President of the Islamic Medical Association of South Africa. In the early 1970’s, a few Muslim Doctors, noting with concern the disparate health services under the Apartheid government of South Africa, embarked upon the establishment of a modest Sunday clinic on the south coast of Natal in Eastern South Africa, where there were virtually no services for the black rural community. This was the birth of what would be called the Islamic Medical Association. With such a deeply personal mission, it did not fade away after the end of Apartheid. Now almost 40 years later, IMA has set up various healthcare and crisis relief centers operating full time in various places in the country where there is dire need for such facilities; social work and counseling are happening for families and children as well. The IMA mission challenges them as healthcare professionals to “establish and project a value system that is a living entity in our own lives, and in the practice of health care solely for the service and the pleasure of the Almighty. ” The health professionals who give their service are truly dedicated to improving primary care for the underserved.
Avril Whate, Vusi Ngcobo, Steve Schmidbauer
One of the many programs that IMA provides here is a small community clinic in Marianhill outside of Durban, a favorite site for CFHI students. One of the services that has been happening for some time now is voluntary counseling and testing (VCT) for HIV. Vusi Ngcobo is the counselor who is responsible for the success of the VCT program here. In an area with such a high prevalence of HIV, it is important that voluntary testing happens so that the virus can be detected as early as possible. For those found to be HIV-negative, they will still receive valuable information about HIV prevention.
The clinic here and the many other projects of IMA are the continuation of a very long tradition of providing healthcare and teaching medical students. I learned that in ancient times, medical education was flourishing in Islamic society as evidenced by written case studies for teaching that date to the seventh century!
During a program visit to South Africa, I continue to be amazed by the dedication, commitment, and resourcefulness of the healthcare workers. I find examples everywhere I go –this one, I wasn’t ready for:
With HIV rates among the highest in the world, you’d think there may be no higher priority in South African health services than addressing this disease and working to prevent it. Meet the new menace, “Tik.”
Dr. Adam has been head of G. F. Jooste Hospital for a little more than a year and in his short tenure, he has witnessed an explosion of drug use in the surrounding community that at times has crippled the functioning of this district hospital. These are the Cape Flats, just ten minutes from the beautiful city center of Cape Town, and there is a real fight here to stop this menace from spreading. The drug is crystal meth, and the impact is devastating. Dr. Adam has had a long and distinguished career as a practicing physician and in more recent years, adding a degree in public health, he has been the doctor/administrator at various facilities in South Africa but he has never seen anything quite like this. They thought they had a challenge seeing 40 or 50 patients per month in the ER who were out of control, high, and totally unpredictable, but now these patients number more than 180 per month, and this is in addition to all other patients seen in the facility. The psychiatric effects of tik (which gets its name from the noise made when the crystalline structure is heated) are severe, and Dr. Adam explains that the ER is not a psychiatric ward. Instead of adding medical equipment, they have been forced to add bullet-proof glass and a metal detector to the entrance area. Patients can arrive in a wild state, combative, and completely noncompliant. “The only choice we have is to sedate them until they calm down and we can begin to help them,” Dr. Adam says, noting that recently one female doctor had to be rescued from underneath a male patient who simply jumped on top of her. This 184-bed hospital is already stretched beyond capacity most every day, and sees 4,500 patients in its emergency room every month. But the evidence suggests things may get even worse. In today’s edition of the Cape Times newspaper, a story by Anso Thom reports that “Tik is the most commonly abused recreational drug in Cape Town…,” and that a new study shows one in ten pregnant women are using tik.
“Tik is holding us hostage in this hospital,” proclaims Dr. Adam. But he is not sitting still. He has formed strong alliances with neighborhood and community groups to help coordinate a positive response from within the community to reclaim its streets and build a network of neighborhood watch and support. He opens the hospital auditorium on Saturdays for community meetings and to provide a safe place for children to come for organized activities. He is most proud of getting approval and funding for an outpatient substance abuse program that will begin very soon. The relentless cycle of treating patients, releasing them, only to have them return in a worse state in only a few days can finally be stopped. Armed with a psychiatrist, an addiction recovery expert, and a local public health masters student to document the progress, Dr. Adam is putting together a team that will take a stand against the menace. Dr. Adam knows that the only way to really fight this new epidemic is to break the cycle of addiction. A holistic approach will aim to help strengthen the family unit as well as the patient. Strengthening the community by strengthening individual families is a plan for wellness in the face of an almost hopeless situation.
“We’ve got to start somewhere,” says Dr. Adam. Reflecting on the toll it has taken on his hospital, Dr. Adam says it would be tempting to say that the hospital is simply not equipped to treat these patients and send them elsewhere. But there is really nowhere else, and Dr. Adam is not the kind of person who could turn a blind eye to a problem like this. You can sense the conviction and commitment in his voice as he says, “Our core business is the health of the community.”
Computer being received at Hospital Civil in Oaxaca, Mexico
CFHI is proud to announce the donation of a Macbook computer to one of our partner sites in Oaxaca, Mexico– the teaching department of Hospital Civil. The donation to the subdireccion de ensenanza department came after the hospital requested this equipment from CFHI as a useful tool in improving operations there. The replacement for the manual typewriter, also in the picture, is a welcome addition to this very busy facility.
The computer will serve in many capacities including logging various activities occurring within the department and in managing the coordination of medical residents working at Hospital Civil. In the photo above from left to right: CFHI Oaxaca Medical Director Dr. Tenorio, Dr. Gabriel Augustin Velasco, the head of Hospital Civil’s teaching department, and CFHI Program Manager Nick Penco, alongside the new computer. CFHI would like to thank the participants of our Global health Education programs as well as support from our donors in making such contributions possible.
Hospital Civil is an outstanding facility with a dedicated staff. CFHI has enjoyed a long relationship with this excellent teaching hospital. This municipal facility is an anchor of the community and has seen everything from the increase of chronic diseases, to the fallout of civil unrest. And Oaxaca was one of the initial detection points of the Novel H1N1 Virus this past year. We commend them on their quick and professional response to what was an unknown crisis. The quality of their work has helped to blaze the trail for everyone working to treat and stop this pandemic.
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.”
As the Executive Director of CFHI, it was indeed a high honor for me to represent our organization and I came prepared to explain our work and our efforts in Bolivia, Ecuador, India, Mexico, and South Africa. To my great surprise, I did not have to do any of that. I found the staff at the NGO Section of ECOSOC wonderfully welcoming and accommodating, and also found they had done their homework and already were quite aware of CFHI and our work. They had read the documents we had sent more than a year earlier in the process of being granted consultative status and they also brushed-up by reading our website prior to my arrival.
What with the UN being such a huge organization, I expected everything to be very bureaucratic and fairly impersonal. Sure it is a big place and with the leaders of the world, about to arrive, there was quite a bit of bustle all about, so it was a surprise to find such personalized service and attention. My meetings with the Deputy Chief of the NGO Section and the Program Officer were cordial and productive.
I learned that there are about 3,200 NGOs around the world that have been granted consultative status. Many are more associated with a cause while they see CFHI as a more “practical” organization. The grassroots nature of our work is appealing to them as well as the diversity of our global family along with the close, long term relationships with CFHI partners who are at the front lines of the delivery of healthcare in so many places. To a large extent, we have our finger on the pulse of global health at the grassroots level and so we have much to share, especially the CFHI model of empowering local communities. Of those more than 3,000 organizations, only about 800 are really active. Work is going on to improve the website of the NGO section and the hope is that there will be much more online functionality to allow for sharing and collaboration.
Flags of the CFHI Global Family now including the United Nations
One official told me, “The international community has looked at your organization from top to bottom and the feeling is that it is a good organization and has a model that is important. We actually hope that it can be replicated in areas of health yes, but also in other areas.” So as we add the UN flag to the flags of nations comprising the CFHI Global Family, we do so with great honor and great pride, and with responsibility for the role that we have assumed through this honor.
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.
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.
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.
The May-June issue of International Educator, the magazine of the Association of International Educators (NAFSA), contains an article by Karen Legget entitled: Teaching Medicine Without Borders. Ms Legget traces the movement from “International Health” to “Global Health” and the impact this is having on medical education.
She looks at various programs from medical schools to organizations (including CFHI) and conducts interviews with students and administrators alike. Her article can be found through the NAFSA website.
In May 2009, President Barack Obama issued a statement on global health. “We cannot simply confront individual preventable illnesses in isolation,” the president said. He continued, “The world is interconnected, and that demands an integrated approach to global health.”
One of CFHI’s newest programs, Sight for All- Ophthalmology Rotation is unique in that it is based out of just one organization- a local NGO located in New Delhi, India. CFHI participants rotate through the various departments, learning how programs and treatment are implemented to reduce preventable visual handicaps. Participants are exposed to mobile eye care clinics, ophthalmic procedures in the operating theater, and take part in advanced level classes at the institute.
The Sight for All program recently had its first participant, Melanie Mamon, and she shares a report on her experiences. To learn more about the program’s location, arrival dates, and clinical sites, click here.
