Building Sustainability
through Short-Term
International Projects: Ethical
Issues in Global Health Work
Parmi Suchdev, MD, MPH
Epidemic Intelligence Service Officer
Centers for Disease Control & Prevention
PEM Fellows Conference
November 15, 2006
Objectives
1. Importance of global health work
2. Ethical challenges & principles for shortterm trips
3. CHIMPS as a model
4. Challenges
5. Resources
State of global child health
Worldwide, 11 million children younger than 5
die each year1
Most from preventable or treatable diseases
Widening gap between the wealthy and poor
3 billion people live on less than $2 a day2
Mortality rate in sub-Saharan Africa was 29x
higher than industrialized nations in 20001
U.S. accounts for nearly ½ of world’s spending on
health, yet it ranks 27th in life expectancy2
1Staton,
Pediatric annals. 2004
2Bezruchka,
Sickness and Wealth. 2004
Causes of under 5 child mortality, worldwide
WHO, 2004
Child health in the U.S.
Only 3% of the world’s 2 billion children
live in the U.S.
Leading causes of mortality in U.S.
children ages 1-4 years:
1.
2.
3.
4.
5.
Accidents (unintentional injuries)
Birth defects
Cancer
Assault (homicide)
Diseases of heart
Why care about the health of children
in developing countries?
Changing demographics of U.S. practices
Increasing immigration, adoption
Increasing travel to developing countries
Educational benefits
Cost-effective, humane way to help other
countries achieve long-term stability
Moral duty
AAP motto: “dedicated to the health of all children”
Recent literature on working overseas
“Duffle Bag Medicine”
JAMA, 2006
“The New Medical Missionaries- Grooming the next
generation of Global Health Workers”
NEJM, 2006
“A Successful International Child Health Elective”
Archives, 2006
“Volunteering Overseas- Lessons Learned from Surgical
Brigades”
NEJM, 2006
Issue on Ethics of International Medical Volunteerism
December AMA Journal of Ethics
International health training
during residency
Over 38% of graduating US and Canadian
medical students participated in an
international health elective in 20001.
Early exposure to international health during
residency promotes continued participation in
volunteer activities after graduation2.
Capitalizing on residents’ enthusiasm and
idealism!
1AAMC,
2000
2Thompson,
et al. Academic Medicine, 2003.
Educational benefits of
international health electives
Improve clinical diagnosis skills
Knowledge and training in tropical
medicine
Attitudinal changes
Public health service, cross-cultural
communication
Recruitment to residency programs
Thompson, et al. Academic Medicine, 2003.
Educational benefits of
international health electives
Introduction to international health
Introduction to new or rare disease
Reciprocal relationships with
participating international institution
Opportunities for language immersion
Service and social responsibility
Federico, et al . Arch Pediatr Adolesc Med, 2006.
International volunteer work for
practicing pediatricians
No set guidelines or norms
Most are short-term volunteer brigades
or training electives
Huge variation in credentialing, clinical
duties, language requirements, religious
affiliations, costs, etc.
No standard of care for trainees
working internationally
International Emergency Medicine
Is international medical work ethical?
Medical Tourism:
“Short-term overseas work in poor countries by
clinical people from rich countries.”
Are reasons people engage in international
work humanitarian or self-serving?
Is the objective to provide mere “band-aids”
that fail to address root causes?
Bezruchka, Wilderness & Environ Med. 2000
Principles of an ethical international trip
1.
2.
3.
4.
5.
6.
7.
Mission
Collaboration
Education
Service
Teamwork
Sustainability
Evaluation
What is CHIMPS?
Children’s Health International Medical
Project of Seattle
Founded by Un of Washington Pediatric residents
in 2002
Organize annual one-week outreach trips to rural
El Salvador, focusing on public health education &
sustainable medical assistance
Ongoing alliance with a local NGO & physician
CHIMPS Impact
Promote opportunities for international experience
during residency
Recipient of 2004 AAP Anne E. Dyson Child
Advocacy Award & 2005 Dyson Community
Pediatrics Training Initiative award
AAP I-CATCH Grant!
http://depts.washington.edu/chimps/
Principles of an ethical trip
1.
2.
3.
4.
5.
6.
7.
Mission
Collaboration
Education
Service
Teamwork
Sustainability
Evaluation
Review Organization’s Mission
Defines core purpose and group’s
collective beliefs
Religiously affiliated?
Government involvement?
Address public health needs of
community?
CHIMPS’ Mission
“To ethically address underlying
health issues and to provide
sustainable public health
interventions and medical assistance
for underserved communities in
developing countries.”
Principles of an ethical trip
1.
2.
3.
4.
5.
6.
7.
Mission
Collaboration
Education
Service
Teamwork
Sustainability
Evaluation
ENLACE
“To Link”
Enhance collaboration between existing
organizations; improve access to technology
Health initiatives
Water systems, health clinics, medical brigades,
nutrition programs, indoor air quality
Local physician
Health committee
http://www.enlaceonline.org/
Principles of an ethical trip
1.
2.
3.
4.
5.
6.
7.
Mission
Collaboration
Education
Service
Teamwork
Sustainability
Evaluation
Educating ourselves
Sociopolitical context
The community
Medical Spanish
Local medical problems
Effective interventions
Where do we go?
Los
Abelines
El Salvador
U.S.
Population
6.5 million
293 million
Life expectancy
71 yrs
77 yrs
Literacy rate (adults)
79%
97%
Infant mortality rate
33%
7%
Under 5 mortality rate
39%
8%
GDP per capita
$2,080
$35,060
The Official Summary of The State of the World's Children, UNICEF, 2004.
Los Abelines community profile
Located in Morazan Department
Focal point for 12-year civil war
Population 1804
61% < age 19
Economic productivity
Coffee, beans, corn, chickens, pigs
Clean water shortage, no electricity or
roads, few latrines, 30% homes straw
Illiteracy rate 70%
Educating ourselves
Learn local language
Understand local medical problems
1. Dental health
2. Intestinal parasites
3. Nutrition
Researching effective interventions
1.
Fluoride varnish1
2.
Empiric periodic deparasitization2
3.
Iron supplements3
1Marinho,
Reduces caries
Effect most pronounced if no other fluoride source
Every 6 month treatment reduces ascaris & hookworm
infection
Prevention of malnutrition and anemia
Prevents loss of estimated 5 IQ points and 10% learning
capacity
Universal supplementation in young children and women
of child-bearing age
Ongoing strategies for preventing iron deficiency preferred
Cochrane Database. 2005
2O’Lorcain,
Parasitology. 2000
3Yip,
J Nutr. 2002
Educating others
The community
Health talks (“charlas”)
Our peers
Publications, speaking opportunities, etc.
Principles of an ethical trip
1.
2.
3.
4.
5.
6.
7.
Mission
Collaboration
Education
Service
Teamwork
Sustainability
Evaluation
Service: “Doing work that the
community needs and wants”
Clinical medical care
Linking the community with the local
physician
Public health interventions
Clinical medical care
“Consultas”/patient visits
Most common acute illnesses include parasitic
disease, malnutrition, upper respiratory
infections, gastroenteritis, and a variety of skin
diseases
Donated medications and supplies per local
needs & WHO drug donation guidelines
Bienvenidos a la clinica!
Gathering health statistics
Things we can treat…
Tooth abscess
Impetigo
Scabies
The difficult cases we can’t…
Public health interventions
1.
Dental Health
Education (“charlas”)
Toothbrushes
Fluoride varnish 3 times/year
2.
Intestinal Parasites
Charlas
Empiric treatment 2-3 times per year
Complement community efforts to build latrines, provide
clean water
3.
Nutrition
Charlas
Iron supplementation
Community garden
Applying fluoride varnish
Now you try it
Best brusher competition…
“Teaching the teacher”
Building confidence
Charlas in action
Principles of an ethical trip
1.
2.
3.
4.
5.
6.
7.
Mission
Collaboration
Education
Service
Teamwork
Sustainability
Evaluation
Teamwork
Our medical
education model:
Faculty
Residents
Local Physician &
Health
Committee
Medical
Students
The Original Dream Team,
CHIMPS 2003
CHIMPS 2004
CHIMPS 2005
CHIMPS 2006
Principles of an ethical trip:
1.
2.
3.
4.
5.
6.
7.
Mission
Collaboration
Education
Service
Teamwork
Sustainability
Evaluation
Sustainability = building capacity
Working in a single location
“Teaching the Teachers”
Augmenting existing systems of care
Respecting cultural norms
Principles of an ethical trip:
1.
2.
3.
4.
5.
6.
7.
Mission
Collaboration
Education
Service
Teamwork
Sustainability
Evaluation
Evaluation
Needs assessment
Identify areas for intervention
Clinical studies
Define extent of problem
Determine efficacy of interventions
Iron deficiency assessment
Iron deficiency is the most common
nutritional disorder in the world
No local estimates of disease burden
Goals
To estimate prevalence of iron deficiency in los
Abelines and associated factors
Implement targeted interventions to treat anemia
Teach local healthcare workers to measure iron
deficiency and follow anemia trends in community
Iron deficiency assessment
Methods
Used donated hematofluorometer to measure
capillary stick ZPPH
Measured anthropometric indicators, diet history,
physical exams
Preliminary Results
N=338 volunteers
Ages 6 months – 89 years
102 cases or 30.2% iron deficient
<1 serving of meat or green vegetables and <2
servings fruit consumed per week
Prevalence of Iron Deficiency by Age
70.0%
% iron deficient
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
<1
1-5
6-10
11-19
Age (years)
20-60
>60
Challenges
Overwhelming need
Impact on other cultures, economies,
and environments
Sustainability
Access and Equity
Meeting expectations
Logistics
Impact on other cultures, economies,
and environments
“Exportation” of value systems
Accentuation of disparities in resources,
material wealth
Medical waste
Creating a perceived need
Inappropriate technology
Foot bridge project in
Los Abelines, 2005
Total cost: $10,000
Sustainability
Personnel
Resources
Institutional support
Hospital and University
Department of Global Health
Partnerships
AAP Section on International Health
Local MOH
Access and equity
Structural determinants of health
disparities
Closing the gap of inequality
Advocating for the rights of children
U.S. only nation not to sign UN Declaration
of the Rights of a Child1
1Kasper,
Ped Annals. 2004
Resources for finding volunteer sites abroad
International Medical Volunteers Association
http://www.imva.org
AAP section on International Child Health Directory of Overseas Opportunities
http://www.aap.org/cgi-bin/overseas/aapartcl.cfm
International Health Medical Education Consortium
http://www.ihmec.org
American Medical Student Association
http://www.amsa.org/global/ih/ihopps.cfm
Health Volunteers Overseas
http://www.hvousa.org
Medics Travel
http://www.medicstravel.org
International Healthcare Opportunities Clearinghouse
http://library.umassmed.edu/ihoc/index.html
International Health Opportunities, University of Colorado
http://www.uchsc.edu/international
Norton. Ped Annals, 2004
Summary
1. Child health is a global responsibility!
2. Short-term international trips can be
done ethically.
3. CHIMPS provides a model for
international initiatives that can be
replicated at other residency
programs.
The Pediatrician’s Gift
-- To touch the life of a child…
Project Participants
CHIMPS
Pediatrics Residents
Parmi Suchdev, MD MPH
Kym Ahrens, MD
Ellie Click, MD PhD
Mollie Greves, MD
Heather Silverberg, MD
Kelly Evans, MD
Esen Garner, MD
Crystal Benson, M
Kim Johnson, MD
Wes Diddle, MD
Malaika Little, MD
Kristina Toncray, MD
Sabrina Guse, MD
Mikelle Bassett, MD
Erica Freeman, MD
Viju Soma, MD
Pediatrics Faculty
Ellie Graham, MD MPH
Cor Van Niel, MD
Maggie Wheeler, MD
Nancy Danoff, MD
Christina Pease, MD
Family Medicine
Julian Perez, MD
ENLACE
Internal Medicine
Oscar Zepeda, MD
Angelina Labella, MD
Physical Therapist
Genevieve Hicks, MSPT
Social Work
Linda Reyes, MSW
Nurses
Jennifer Gould, RN
Blanca Drumm, RN
Shannon Chappon, RN
Elizabeth Karmen, RN
Lisa Marie Mesa, RN
Julie Sharples, RN
Others
Debra Weissman
Rajni Gunnala
Chris Williams
Elena Villata
Lori Macklin
Chris Macklin
Alfredo Aguilar
Doris Evangelista de Leon
Sonia Rodriguez de Rosales
Alexendra Yarosevich
David Mcgee
Walter Bolanos Rodriguez
Dr. Mireia Salazar
Dr. Glenda Henriquez Perez
Dr. Mirna Garcia
NU-AID
Julie Piskur, MD
Leslie Ramirez, MD
Greg Brisson, MD
Medical Students
Kevin Gobeske
James Wysock
Katie Chell
Adam Romeiser
Juan Ambrose Insua
Vivien Leung
Sara Boblick
Los Abelines
Health Committee
Blanca Rosa Villalta
Dalila Amaya
Rosa Membreno
Fide de Paz
Reina Franco
Mercedes Portillo
Celio Andrade
Patrocinio Villalta
Humberto Martinez
Nelson Paz
Aristedes Pineda
Anibal Reyes
Miguel Angel Pineda
Santos Guzman
Rosalina Portillo
Olinda Parada
Yanira Orellana
Adelina Pineda
Vilma de Prarada
Victorio Paz
Vicente Guevara
Enrique Cabrera Avelar
Jose Vicente Moreno
Flor Parada
Reina Martinez
Julia Medrano
Zulma Pineda
Juan del Cid
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2000;11:77-8.
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