Tag Archives: primary health care

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.DSC_0918

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

The Rio Political Declaration

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Heads of State vow to “achieve social and health equity.”  Students respectfully ask for more specifics.

Last week, Heads of State, Ministers, government representatives, and leaders of different sectors met in Rio de Janerio at the WHO World Conference on Social Determinants WHO Logoof Health.  (Writing and discussions  about social determinants of health can often get lost in very academic and sterile sounding language, so it is important to keep it as close to real life as possible.)  What is important about the World Conference on Social Determinants of Health (WCSDH) in Rio is that 125 nations pledged their commitment to work to promote awareness, develop policies, and support programs to transform certain social factors that play a significant role in determining whether or not a person will be healthy.  The U. S. Centers for Disease Control uses the following words in an attempt to define ‘Social Determinants of Health’, “…complex, integrated, and overlapping social structures, and economic systems that are responsible for…”  As you can see, we are already getting off into language that feels far removed from the daily realities of global health disparities like lack of access to care.  Of course, all this has to do more with economics, education, and politics than with the common understanding of health and healthcare.  And that is exactly the point.  The fact that many high level political decision makers were present in Rio gives us some hope that there is a growing realization that health ministers alone cannot address these issues.

The Rio Declaration referenced a similar conference in 1978 that produced The Declaration of Alma Ata, named for the Russian city –then in the USSR, where health was defined as “…a state of complete physical, mental, and social wellbeing, and not merely the absence of disease of infirmity… .”  It went on to declare health as “a fundamental human right.”  So we have known for a very long time that the goal of health for a nation and for the world is larger than healthcare, at least as we know it in the United States.

More than thirty years later, it is great to see the Spirit of Alma Ata is still alive.  For, as economics, politics, and situational specifics change, it is imperative to remember that fundamental values and rights remain constant.  It was right for Alma Ata to call for essential primary healthcare for all the world’s population back in 1978, and it is right for Rio to say today that just because we have not yet achieved the promise of Alma Ata does not mean that we should stop trying.

Progress is being made, but there is much more that can be done.  That is why it is good to see the fresh eyes of students also present at the Rio conference.  The International Federation of Medical Students (IFMSA) sent a delegation of ten medical students to Rio.  Their take on the events of the WCSDH can be found on the IFMSA blog.  While the IFMSA students don’t have the experience of some of the professionals who have been working at this for several decades, they do bring a fresh perspective and the ability to think more simply, with less jaded minds.  In their critique, Renzo Guinto, the leader of the youth delegation, hits the nail on the head by saying: “The main problem of the Rio Declaration is that it failed to explicitly tell us how the unfair distribution of power, resources and wealth will be addressed, especially by Member States. The WHO Commission on Social Determinants of Health has been adamant about the need to tackle this lingering issue, as health inequities within and between countries are rooted in power relations and resource maldistribution. We understand that changing the current dynamics of power will not happen overnight. However, we believe that this Declaration could have been the watershed moment for leaders to make a strong commitment in making this world a fairer place.”

Students who participate in any of Child Family Health International’s (CFHI) Global Health Immersion Programs are, in fact, immersed into underserved communities around the world.   They are mentored by local healthcare workers who face the challenges of few resources and many patients.  Students say that they are deeply impacted as they see dramatic health disparities and the realities of the social determinats  of health playing out right in front of their eyes.  They become some of the most effective advocates for global health equity because they are eye witnesses to the consequences of inequity.  And some of them are moved enough to have the experience directly impact their career plans, like Erin Newton who wrote about her experience on the Great Nonprofits Website. “Having never been exposed to the poverty, illness, and disease that I experienced in India, I learned so much about myself and found that I have a true passion for underserved and rural patient care. I learned that much of it can be prevented and I want to help treat these individuals and educate the rural communities as a future physician.”

Along with his challenges, Mr. Guinto also seems to speak for IFMSA in pledging to “…commit ourselves to continue engaging with all sectors involved in the work towards global health equity, spreading awareness of the social dimensions of health to our fellow young people, mobilizing them to take action in their respective communities and countries, doing our part, little by little, but with courage, constancy, and conviction.”  We call on all CFHI alumni, whether they be part of IFMSA, AMSA (America), AMSA (Australia), ASDA, NSNA, SNMA, as well as many other groups, or just individual health science students, to read Mr. Guinto article and find the best way to engage in the great effort to achieve heath equity both at home and abroad.

With additional specific yet respectful challenges, Mr. Guinto offers an important contribution to the dialogues around social determinants of health that may require the veterans of this work to take a step back and refocus for a fresh look at what is taken for granted, or thought to be impossible.  For it is only that kind of courage that will produce the bold steps needed to truly transform the status quo and bring about the promise of Alma Ata that is still waiting for us all.

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

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Map of Austraila and Tasmania

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

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.

GH Conference Hobart

Panel discussion at the Global Health Conference Hobart Tasmania July 2010

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.

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.

  1. 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.
  2. 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.

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.