A Practical Guide to Global Medical Volunteerism

A PRACTICAL GUIDE TO GLOBAL MEDICAL VOLUNTEERISM

The health of people around the world is said to be a global responsibility, one, which is shared and often spearheaded by physicians in the United States. How can physicians from the United States help build sustainable international medical projects and what practical, financial, and ethical issues must be considered before undertaking these endeavors. You are listening to a ReachMD, The Channel for Medical Professionals. Welcome to a special segment - Focus on Global Medicine. I am your host, Dr. Jennifer Shu, Practicing General Pediatrician and Author. Our guest is Dr. Parminder Suchdev, Assistant Professor of Pediatrics and Global Health at Emory University and Medical Epidemiologist in the Nutrition Branch at the Centers For Disease Control and Prevention in Atlanta.

DR. JENNIFER SHU:

So, welcome Dr. Suchdev.

DR. PARMINDER SUCHDEV:

Thank you.

DR. JENNIFER SHU:

So, why do you think physicians are becoming more interested in global health?

DR. PARMINDER SUCHDEV:

Well, I think it's quite evident that the interest has blossomed and I think there is a lot of reasons and the one that I think on the more practical level for those who are out in a community practicing is that, you know, many patients that you see on a day-to-day basis are from the countries themselves and are immigrants and just due to this I think there is an increased interest in understanding the cultures and understanding where these patients come also just increasing travel of Americans themselves to other countries is also increased awareness of health issues.

DR. JENNIFER SHU:

Are there also more international health opportunities for physicians in training such as medical student and residents?

DR. PARMINDER SUCHDEV:

Absolutely, absolutely, and I think this has been demonstrated quite well. The AMC done an annual poll where they asked medical students, "have you participated in international elective" and if you look at that graph, it's gone up from about 10 to 15% in the 90s and most recently in 2008 they did a web survey of all the 200 or so medical schools and found that about half of all medical schools are offering some type of international health experience. So, there is definitely an increase and this also happens beyond the medical student level even that once people go on to residencies, there have been some recent service too in the pediatric program for instance that also showed little over half of all residency programs are also offering some type of global health experience. So, yeah, that interest is definitely increasing.

DR. JENNIFER SHU:

Physicians and trainees who are interested in international health work may not realize that they are some ethical challenges and I want to just go through these one by one and hope you can elaborate little bit, but some critics say that these trips are self-serving for the people who go on them. What are your thoughts on that?

DR. PARMINDER SUCHDEV:

Anyone who has gone abroad will often save his experience. The first time I did a global health experience for intense when I was an undergraduate coming back and just, you know I did get more out of this than the community I served. Thus, when you go as a trainee, do you feel like you have the resources and the knowledge to provide the care that is needed. Our medical system training is focused on tertiary care. When see a patient who comes with fever and cough, we get a chest x-ray to make the diagnosis of pneumonia, but when you are in a developing a country context, use your stethoscope and your history to make the diagnosis and so often we are trained to provide the care in global health setting. So, often the feeling is that maybe those who go abroad are getting more out of it than the community we serve and is not mutually beneficial.

DR. JENNIFER SHU:

I mean, but clearly of the patients abroad do benefit from the people out been there to help, but one other criticism is that because of the lack of health care access and certain laboratory tests and diagnostic procedures that you just can’t follow current standards of healthcare delivery or provide continuity or access and what you state as a trivial, you know when a short-term trip really can't provide that continuity.

DR. PARMINDER SUCHDEV:

I really think it can. I think lot of people have felt this, myself included, that maybe continuity is impossible. The guidelines we learn here in the United States cannot be applied, but I think it can be in international organizations you know such as World Health Organization that has criteria to make diagnosis and provide care and these interventions have been shown to be effective and usually to problem is that the lack of knowledge or to lack of diagnostic tools that is really just the resources to get these and to apply these interventions and going back to pneumonia, I mean if with a fever and cough and developing country context that's going to be pneumonia and with low antibiotic resistance giving an appropriate antibody is going to result in beneficial impact. So, I think it can be done.

DR. JENNIFER SHU:

Could following up patient populations and performing a research in international settings produce also an ethical challenge? What kind of IRB might be used overseas?

DR. PARMINDER SUCHDEV:

When you talk of more on to the research site of doing international health work that definitely raises additional issues beyond just when are doing clinical care and that's actually where ethical guidelines are actually better established for doing research and it really depends on the context of where you are doing the work, whether you are doing it with the University or through a non-governmental organization, for instance, and most countries do have a local IRBs or Institutional Review Board or some version of an ethical review committee and it's really important to adhere to these when doing research. But I think more research definitely needs to be done because in lot of context the resources aren't there and the training is not there to do research and someway that's probably the best tool we can offer as physicians from the US going abroad is to provide research and provide tools to do evaluation of existing programs.

DR. JENNIFER SHU:

And you recently co-authored an article in the Ambulatory Pediatrics Journal detailing some guiding principles for international health work to kind of overcome these challenges that we have been talking about. Can you give us a highlight of what some of those guiding principles might be?

DR. PARMINDER SUCHDEV:

This model was created by those who have done international work and felt that these ethical challenges were common challenges that anyone faces and we were really looking for some type of tool to help guide work that's done abroad, and when we looked to the literature there really wasn't anything out there, there were just fewer guidelines, which in 2004 were created to guide humanitarian relief in response to disaster, but that's not really in most cases when physicians do short-term clinical work and so basically these guidelines were just set up to look at a program, both whether you are creating a new program or if you are just looking at a list of programs that are out there on the web for instance in deciding which of these program best serves me and then what will be the most valuable for my own career and educational development and the seven principals are mission, collaboration, education, service, teamwork, sustainability, and evaluation.

DR. JENNIFER SHU:

Now, in you 7 guiding principals, one of them collaboration and making sure that there is a good relationship between the aid group and the community of serving. Howe do you make sure that the local community is able to sustain the medical work once the aid group leave and this is financially also having an infrastructure to do so.

DR. PARMINDER SUCHDEV:

Absolutely and I think, you know, part of the first step in setting up a collaboration with a local institution is to really understand what that institution’s mission is and understanding what their objectives are and serving needs that they feel are important, not necessarily what we or person traveling feel is important, and I think if you pick a project that is beneficial to the host community than sustainability is more likely to be insured because it will be valued for instance spending all these review sources to do a project on the HIV/AIDS and really the host community doesn't have resources to provide ongoing treatment for HIV/AIDS versus they really feel that, you know, nutrition is a big problem, you would be wasting your time because once you leave the project, it would no longer sustains. I think its really communicating effectively with the local organization in finding out what they feel is most important to them.

DR. JENNIFER SHU:

So, that kind of goes right in to service as one of your 7 guiding principals and that's the commitment to doing the work that the community actually needs and wants. In your experience and places that you have worked, what are some of the more manageable service goals that you can try to achieve in these international communities?

DR. PARMINDER SUCHDEV:

In my experience, the risk kind of goes into two parts, those of us who are clinical providers are trained to do clinical work whether that's seeing patient, doing a history and physical, providing short-term acute care for manageable condition. But there is also another piece of that which is public health intervention and that's something that we are often not trained in as medical providers, but something that we can really provide and whatever I mean by public health interventions might be let's say the problem of diarrhea. So, you might see in your clinic, 10 kids with diarrhea and might offer like oral rehydration solution to treat the diarrhea, IV fluids if it is a severe case, but that's not going to really address the source of the problem with the diarrhea, which is problems with safe water, problems with hygiene and so you might argue that your service goals might be better served focussing on education on hygiene, interventions to address safe water for instance, providing chlorine tablets to treat the water, may be bring a group of engineers to help address some of the access to water problem, and really focussing intervention to your service on public health we will have more sustainable impact.

DR. JENNIFER SHU:

Your paper also mentions the development of dental health and how fluoride varnishes might be one manageable way to make an intervention. The other issue is issue of nutrition. Another problem is the issue of nutrition in some of these countries where people may not have access to healthy foods. How do you tackle such a rod subjective like that?

DR. PARMINDER SUCHDEV:

Much of my research focus is on nutrition here at the CDC and there are lots of approaches you can take to address malnutrition and it remains to be the most common cause on over half of all childhood deaths in developing country context are associated with malnutrition. So, it's a universal problem in doing global health work and I think you mentioned that the acute problem is easiest to a kind of recommend dietary diversification, access to food, but when you have poverty, this is often not possible. So, the other interventions that can be used for instance supplementation, whether it is iron supplementation or multiple micronutrient supplementation. One program we have introduced recently in both Kenya and Haiti is the micronutrient powder called sprinkles that looks like a packet of sugar and it's applied directly to the food and each sachet only cost about 1 US cent and the idea is that you take the existing food that's available in the family that might be very nutrient dense and make it better and healthier and the sustainability and the acceptance of this product is very high.

DR. JENNIFER SHU:

In your paper you state that even with the best intentions and proper planning there are patients for whom adequate care cannot be given and well meaning interventions can have unexpected effects. What are some examples of that?

DR. PARMINDER SUCHDEV:

One example that I recall in El Salvador when I worked there as a resident was working in the rural community called Los Avellanos in rural El Salvador and a group of engineers came and in well intention decided to build a footbridge across one of the streams that ran toward the community, was the main source of water for the community, and during the rainy season, this stream would get flooded. So, they built a fancy metal bridge, bought welding equipment. The total cost was about $30,000 and it might have served the community well, but for instance the week following this intervention, a child had fallen off the bridge and broken his arms and so that was an unattended consequence for this footbridge and may be the money and resource has been better used to, for instance improve nutrition or improved access to water. Another case that happened with me was taking inappropriate medications that you might not realize would be needed that are often donated by pharmaceutical companies, for instance, we had hundreds of inhaled steroids that were donated and taking these into another country where more acute management of asthma or respiratory conditions is needed and inhaled steroids might not be as accepted then the medical ways that's left behind by all the plastic and the metal is often something that needs to be considered as well.

DR. JENNIFER SHU:

I would like to thank our guest, Dr. Parminder Suchdev. We have been discussing the practical, ethical, and financial considerations of international voluntarism.

I am Dr. Jennifer Shu. You have been listening to a special segment - Focus on Global Medicine on ReachMD, The Channel for Medical Professionals. Please visit our website at www.reachmd.com which features on-demand pod casts of our entire library. Thank you for listening.

Thank you for listening to our special series, Focus on Global Medicine. As we celebrate this annual holiday season, everyone at ReachMD wishes you and your family a happy holiday and a successful New Year.

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