Exemplar of Ethical Global Health Service

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Physicians and other healthcare providers who work in developing and under-developed countries on behalf of non-governmental organizations have special ethical duties in addition to applicable laws. Heightened attention to ethical conduct is especially important amongst populations that are ill positioned to advocate for themselves in the absence of compliance with such principles. Furthermore, without such ethical adherence, under-served populations may even be more harmed than benefited in certain circumstances. Poorly executed programs squander funding, divert resources, and raise false expectations amongst persons in need. Concern Worldwide’s Innovations for Maternal, Newborn & Child Health Program offers a model of exemplary approaches for replication. The approach presents a societal parallel to individual patient care, and thus also offers the opportunity to reflect about rigorous ethical standards of medicine.

Building capacity for birth defects surveillance in Africa: Implementation of an intermediate birth defects surveillance workshop

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Each year around the world, it is estimated that 300,000 neonates are born with a neural tube defect. Many countries, however, are still lacking comprehensive birth defects surveillance registries. Comprehensive birth defects surveillance systems can help countries understand the magnitude and distribution of the problem. These systems can also provide information about biological, contextual, social and environmental determinants of birth defects. This information in turn can be used to identify effective and implementable solutions, and to evaluate prevention and management strategies to improve quality performance. This paper summarizes the development and implementation of an online pre-course training and in-person surveillance workshop conducted between 2014 December and 2015 March for representatives from six African countries. Feedback given by participants provided valuable lessons learned that can be applied to subsequent trainings and workshops.

Short Term International Medical Volunteerism in Higuey, Dominican Republic: A Student’s Perspective

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Short-term medical missions provide students with the opportunity to aid healthcare professionals in the treatment of patients with severely limited access to care. They also provide ample opportunities for students to learn about differences between healthcare in the United States and global healthcare. In the Dominican Republic, there is disparity with respect to wealth and limited access to healthcare. I participated in a medical mission to Higuey with the nonprofit medical group Guardians of Healing and saw the value of medical missions firsthand. The Guardians of Healing ran a clinic and performed surgical procedures in cooperation with a regional hospital. Community members were invited to receive free medical care at the clinic through word-of-mouth and the distribution of flyers throughout the town. Management of immediate medical concerns was a critical aspect of the mission. The majority of surgical cases seen were cholecystectomies and hernia repairs. Other cases included adult circumcision and removal of a trichilemmal cyst. Common clinical complaints included fever, lethargy, and hypertension. In treating these patients, cultural sensitivity was essential, as was the full sharing of care objectives. Coordination and cooperation with the regional and national governments were crucial to the successes of these endeavors. Everyone involved appeared to benefit from this medical mission, whether through the receipt of direct medical care or through the ability to help others while learning about different cultures and healthcare environments. This experience allowed me to compare medical care, customs, and cultural trends between the United States and the Dominican Republic.

International Aid with a Long-term Perspective: Proposed Guidelines for Effective Development through Community Partnerships Based on the Haitian Experience

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The attainment of adept international partnership outcomes in the global world — particularly in exacerbated settings such as Haiti — is hampered by a lack of sustainability principles and limited capacity building opportunities, such as institutional development. This is further compounded by the unintended consequences of volunteerism in service provision and inadequate empowerment of local communities. Although volunteerism may provide lower income countries with benefits, there are impending pitfalls. Since this form of assistance is compartmentalized, rather than institutionalized, the capacity building of the society remains isolated. This risks fragmentation when greater cohesion is necessary. The conditions in Haiti call for more strategic partnerships to harness and realize latent development potential. Institutional partnership is an effective methodology for developing pertinent interventions with socially marginalized communities; although implementation is challenging, it is necessary for long-term change. To effectively attenuate social disparities in poverty stricken, chronically underserved populations, and interventions must act collaboratively. In order to diminish social disparities one must address issues of access, information, and knowledge to reduce barriers to innovation and social change. This paper presents a bilateral partnership between the Université d’État d’Haïti (UEH) and the University of California (UC) and describes the principles used to stimulate effective development that sets the stage for an institutional partnership and innovation in global sustainable development.

Funds for Felix: A Global Collaborative Effort to Restore One Patient’s Vision

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Undergraduate students volunteer with Global Medical Training (GMT) to provide free clinical services to underserved individuals in Central America. Some patients are unable to physically travel to GMT makeshift clinics because they are excessively impaired by their medical conditions. In these circumstances, physicians and volunteers make home visits to assess how to effectively help such patients. During one visit, GMT volunteers and physicians were so moved by a patient’s crippling vision loss that they refused to be passive observers of his condition. Two undergraduate students spearheaded an international collaboration, called Funds for Felix, to raise money for a surgery to salvage what was left of this patient’s vision. However, several months after the initiation of Funds for Felix, volunteers learned that the patient had dramatized the circumstances leading to his visual impairment. After thorough review of the patient’s predicament, Funds for Felix decided to continue supporting the patient and his family. Though it was ultimately discovered that ophthalmological intervention for this patient would be futile, Funds for Felix helped him enroll in a Braille school in the Matagalpa region of Nicaragua so he could learn how to read. These efforts significantly improved this patient’s self-esteem and instilled in him hope for a more fulfilling life.

The Ethical Dimensions of Focusing Global Health Efforts on a Single Patient: an Examination of “Funds for Felix”

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This article analyzes the ethical considerations involved in focusing a global health effort on a single patient. The specific case considered is “Funds for Felix”, in which money was raised by students for a patient encountered by the UCLA Global Medical Training trip to Nicaragua in December of 2010. As the leader of the UCLA campus branch of Global Medical Training, I approach this case from a broader, organizational perspective. Although the Global Medical Training at UCLA leadership body was enthusiastic about the Funds for Felix project, we wondered about the potential ethical concerns that arise from devoting so many resources to an individual. Ultimately, the approach taken for the Funds for Felix project was extremely successful. This was due to several factors, including the transparency with which the project was conducted, the involvement of Nicaraguan mentors, and the students’ altruistic motivations. Given the rising awareness of global health issues, the relevant ethical questions of the Funds for Felix project are salient for any student or physician in the field of global health.

The Sustainability and Impact of Medical Camps in the Slums of Bengaluru, India

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A medical camp was conducted at the Whitefield slum in Bengaluru, India with the assistance of volunteers from: the Keshava Seva Samithi (local NGO), Youth for Seva (local NGO), Qcare (Qualcomm IT company-Bengaluru branch),Vydehi Institute of Dental Sciences, and Nethradhama and Lions’ Airport City Hospital. At this event the local patients directly consulted with a general physician and/or specialists in a converted school house. This type practice has been the most common form of providing access to healthcare for vulnerable populations. Over a 6 hour camp operation, 324 patients of varying ages were registered to consult with an ophthalmologist, dentist, and general physician. As in most camps, the physicians here did not have a patient history, and as such, the efficiency of this and similar efforts are suboptimal. The public-private partnership efforts of corporate volunteers through corporate social responsibility initiatives was a unique feature of this camp. This report outlines the process of the health camp, the appropriate resources utilized, the methods available for follow-up, and areas of improvement for future camps. The efficiency of the camp through the use of volunteers and the direct and indirect short- and long-term effects of such efforts were evaluated.

The Cultural and Psychological Context of Development and Healthcare in the Tribal Region of Sargur, India

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Located 55km northeast from Mysuru, the isolated region of Sargur, India is a highly forested and remote area. The population of this region is considered a minority and vulnerable due to lack of access to care, low life expectancy, and high levels of poverty. This tribal group has a unique culture, language, and way of life that is novel to outside medical professionals or development leaders that attempt to work in the region. To better serve the community and improve access to care, the Swami Vivekananda Youth Movement (SVYM) created an integrated development model which customizes the current standard development models to accommodate the tribal value system and attitudes regarding education, health, and socioeconomic empowerment. This report summarizes how the revolutionized education and healthcare system addresses the challenges of catering to a population prone to migration through understanding the definition of health according to the local attitudes and interpreting the impact of way of life in the development models appropriate for this population. This report reinforces the integral role of cultural competence when attempting to work with marginalized populations. The local approach varied from the traditional development models and was based off of direct experience with the population and cultural competence. This account analyzes the cultural norms of the tribal individuals, evaluates the appropriate technology and interventions used within the region, and assesses the barriers to healthcare and sustainable development.

Breaking Bread Together: The Convergent Development of Accompaniment in Secular and Catholic Global Health Efforts

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While both the Catholic Church and the WHO claim to have a preferential option for the planet’s poorest inhabitants, they have often disagreed vehemently about how such an option should be provided. In recent years, the Catholic Church and WHO’s opposing stances on international health issues have been thrown into sharp relief, especially by their disagreement on use of condoms as a means for enhancing sexual health and inhibiting the spread of STIs. However, both Catholic and secular global health efforts agree on at least one critical means for alleviating global poverty: accompaniment. Accompaniment denotes the provision of long-term healthcare and social support from the level of individual communities and has deep roots in both Catholic social teaching and modern trends in secular global health. In spite of this apparent harmony, accompaniment’s inherent enemy, social sin, is dichotomously defined by the Catholic Church and the secular global health movement. The Church identifies social sin as a sin committed by an individual which drags down with itself the church and, in some way, the whole world. By contrast, the secular global health movement tends to identify social sin as an oppressive transgression upon the autonomy and human rights of the individual by an empowered social group or government. This division over social sin is likely to be more alienating than their agreement on accompaniment is unifying.

Using Cultural Competence to Improve Tuberculosis Case Detection and Treatment Adherence in Ethiopia: A Framework for Redefining the “Obvious”

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In this paper, we reorient the use of a culturally competent approach to improving case detection and treatment success for tuberculosis (TB) in Ethiopia. We focus on two distinct groups, TB patients and TB susceptibles, using the Purnell model of cultural competence. Through personal observations and interactions, we assess the cultural dynamics in each group that proliferates the stigma, preventing case detection and treatment adherence. We develop a conceptual critique of the current health extension package in Ethiopia to produce two main findings regarding future TB control in Ethiopia: (1) the use of local health extension workers does not mitigate the need for continued cultural competence to improve case detection and treatment adherence; and (2) the target of culturally competent care may need to be re-oriented to community members without disease to establish a prevention framework that attenuates the socially-imposed discomfort of seeking diagnosis and treatment. Taken together, we propose that health extension workers may enhance efficacy of TB detection and treatment by identifying more with individuals without disease. We thus propose a culturally-motivated two-tiered health extension worker model to initiate a shift in the public perception of how TB patients are viewed in their communities.

Cruzada de la Esperanza

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Cruzada de la Esperanza, women's health, rural Honduras

Dr. Eduardo Gonzalez Martorell and Maria Teresa Gonzalez de Andrade of COCSIDA discuss a pilot public health project in Honduras aimed at providing women’s health services.

International Aid with a Long-term Perspective: Proposed Guidelines for Effective Development through Community Partnerships Based on the Haitian Experience

·

The attainment of adept international partnership outcomes in the global world – particularly in exacerbated settings such as Haiti – are hampered by a lack of sustainability principles and limited capacity building opportunities, such as institutional development. This is further compounded by the unintended consequences of volunteerism and inadequate empowerment of local communities. Although volunteerism may provide lower income countries with benefits, there are impending pitfalls. Since this form of assistance is compartmentalized, rather than institutionalized, the capacity building of the society remains isolated. This risks fragmentation when greater cohesion is required. The conditions in Haiti call for more strategic partnerships to harness and realize latent development potential. Institutional partnering is an effective methodology for developing pertinent interventions with socially marginalized communities; although implementation is challenging, it is necessary for long-term change. To effectively attenuate social disparities in poverty stricken, chronically underserved populations, interventions must act collaboratively through unyielding institutional partnerships. In order to diminish social disparities one must address information and access issues to reduce innovation barriers. This paper presents a bilateral partnership between the Universite d’Etat d’Haïti (UEH) and the University of California (UC) and describes the principles used to stimulate effective development and sets the stage for an institutional partnership.

When Culture Meets Medicine: Reflections on a Medical Mission to Cameroon

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The West-African nation of Cameroon is one with limited access to health care, with a ratio of only 1.9 physicians per 10,000 people. Such statistics demonstrate the health care needs of this country; however, personal experience provides a much more striking perspective of such health care disparities. Because of a five-week medical mission trip to Cameroon, I have come to better appreciate the need for health care providers around the globe. During my visit, our team of health care providers, in collaboration with the Cameroonian organization ASCOVIME (Association des Compétences pour une vie meilleure), was able to provide free medical care to over 1,500 Cameroonians from the rural villages of Minkang II, Lomie, Doukoula, and Nditam. These villages warmly welcomed our team, enabling us to provide care through general consultations, ophthalmology screenings, and surgical interventions while being immersed into Cameroonian culture.

Food Security Monitoring and Evaluation in Dissan, Rural Mali: Preliminary Findings

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African Sky is a non-profit organization that has been continuously involved in community development efforts in the Sikasso, Koulikoro, and Segou regions of Mali since 2001. This assessment focused on the rural village of Dissan, in the Sikasso region. During the evaluation period between 2001-2010 Dissan experienced highly variable rainfall. It was hypothesized that these conditions would negatively impact farming output, and as a result, nutritional status of the people living in Dissan. Between 2001 and 2010, African Sky Executive Director Scott Lacy conducted ethnographic field research to document how Dissan farmers manage to feed their families despite scarce resources, difficult growing conditions, and highly variable rainfall. As part of this research, Lacy conducted two censuses and two surveys that included all households living in Dissan (2001, N=66; 2010, N=73). Common variables in both surveys overlapped on key areas such as crop varieties and land usage; these variables track household food production and farming trends from 2001 to 2010. This report draws upon overlapping data from household censuses and surveys to determine if interventions implemented by African Sky and Dissan households had an impact on food production as a proxy for nutritional status. Initial analysis shows no significant reduction in the hectares of land cultivated (p-value = 0.546). The number of sorghum varieties grown increased from 1.3 to 3.9 per household (p-value

Short-Term International Medical Volunteerism in Higuey, Dominican Republic: A Student’s Perspective

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Short-term medical missions provide students with the opportunity to aid physicians in the treatment of patients with severely limited access to care. They also provide ample opportunities for students to learn about differences between healthcare in the US and global healthcare. In the town of Higuey, Dominican Republic, wealth and access to healthcare are minimal. I participated in a medical mission to Higuey with the nonprofit medical group Guardians of Healing. I saw firsthand the value of medical missions. The Guardians of Healing ran a clinic and performed surgical procedures in cooperation with a regional hospital. Community members were invited to receive free medical care at the clinic through word-of-mouth and the distribution of fliers throughout the town. Management of immediate medical concerns was a critical aspect of the mission. The majority of surgical cases seen were cholecystectomies and hernia repairs. Other cases included adult circumcision and removal of a trichilemmal cyst. Common clinical complaints included fever, lethargy, and hypertension. In treating these patients, cultural sensitivity was essential, as was the full sharing of care objectives. Coordination and cooperation with the regional and national governments were crucial to the successes of these endeavors. Everyone involved appeared to benefit from this medical mission, whether through the receipt of direct medical care or through the ability to help others while learning about different cultures and healthcare environments. This experience allowed me to compare medical care, customs, and cultural trends between the US and the Dominican Republic.

Understanding Women’s Intergenerational Knowledge Transfer in Rural Mali: Lessons from the African Sky Mothers and Daughters Summit

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In January 2011, the nonprofit African Sky facilitated an educational conference in Markala, Mali at the request of women’s associations in rural partner villages. The Mothers and Daughters Summit was a venue for pre-existing associations to come together and share knowledge and skills for mutual benefit. The participating groups (N = 6) held expertise in areas of: 1) organizational management, 2) income generation, and 3) family health and sanitation. Proficiency was measured on a four-point scale (1 = below basic, 2 = basic comprehension, 3 = proficient, 4 = advanced proficiency) for 14 items across the three areas of expertise. Evaluations were conducted pre- and post-intervention. The participating associations can be grouped as “established” peri-urban (N=2) and “emerging” rural (N=4) associations. The evaluation of the summit showed proficiency levels of 87% on measures of organizational management and family health and sanitation, and 50% on measures of knowledge of income generation. Six months following the summit, the two established women’s associations achieved 100% proficiency in organizational management, family health and sanitation, and income generation. The emerging women’s associations reported less promising results after six months. Three emerging associations were lost to follow up, and the one that remained showed a decrease to 50% proficiency in income generation, and only 10% proficiency in both organizational management and well as family health and sanitation. Organizational management and family health and sanitation showed larger gains than income generation. The authors predict this is because these topics are better understood, whereas formalized income generation is a newer topic being introduced to the groups. It is likely that being from larger towns, the participants from the established organizations had more experience with formal education. The emerging organizations did not have an opportunity to practice their new skills because they did not have the minimal startup funds necessary. The authors hypothesize that the gains were maintained in the established organizations as these associations had the monetary means to implement the business plans they developed at the conference. Using peer-to-peer mentoring as a model for teaching skills proved effective for skill-sharing in this sample of rural women’s associations in West Africa. Organizational support for immediate application of newly acquired skills may increase retention of skills and knowledge.

“Cruzada de la Esperanza” (Crusade of Hope): Promotion, Prevention and Diagnosis for Breast, Cervix and Uterus Cancers, Sexually Transmitted Diseases and HIV-AIDS in Honduras Rural Areas 2008-2009

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A pilot public health project in Honduras aimed at providing services for promotion, prevention and diagnosis of breast, cervix and uterus cancers, sexually transmitted diseases and HIV-AIDS was implemented. “Cruzada de la Esperanza” targeted 789,415 women of fertile age older than 18 years in impoverished and hard to reach rural areas. The project was funded by The China-Taiwan Republic and The Honduras Health Ministry. “COCSIDA” Centro de Orientación y Capacitación en SIDA (Center for Counseling and Training on HIV–AIDS) was the institution administrating and implementing the project in 108 municipalities and 576 villages. The health threats in this population are due to the close relationship between women’s reproductive health issues and components of human sexuality; influenced by socio-cultural factors expressed through male “machismo”; female subordination and lack of empowerment and education. The project’s demographic coverage was every person who directly or indirectly benefited from the services. The criteria for intervention were those for the targeted health threats and pregnant women. The Crusade’s main goal was to decrease late detection for the stated cancers and other health problems. Another goal was the increase of access and services utilization including mammography, vaginal cytology, rapid HIV testing and counseling, diagnosis of sexually transmitted diseases and positive case referral to a higher quality health care center. By achieving the above goals the Honduras female population was educated to adopt better and safer health care practices and access to those services will increase. The main strategy of implementation was the use of 3 mobile mammograms, radiological and laboratory diagnostic equipped vehicles available in a community health fair atmosphere. The plan was to provide 10,800 mammograms, 25,920 ultrasounds, 25,920 vaginal cytologies, 12,920 HIV tests and 20,000 sexually transmitted disease attentions. The crusade began in May 2008 but ended in March 2009. A total of 102 municipalities in 13 departments and 263,242 people were serviced. A total of 330,154 attentions out of 312,736 planned (105.6%) was accomplished. Of these, 15,390 were mammograms, 9,187 were ultrasounds, 27,271 were cytologies, 13,681 were HIV tests and 8,808 were STD attentions. 305 vaginal cytologies and 70 mammograms were suggestive of malignancy. 21 cases were HIV positive. 100% of the suggestive malignancy and HIV cases were referred and inserted in a specialized institution for medical care. Due to the successful results, the funding donor entities granted one more year of activities, sadly canceled due to the Honduras political crisis.

Funds for Felix: A Global Collaborative Effort to Restore One Patient’s Vision

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Undergraduate students volunteer with Global Medical Training (GMT) to provide free clinical services to underserved individuals in Central America. Some patients are unable to physically travel to GMT makeshift clinics because they are excessively impaired by their medical conditions. In these circumstances, physicians and volunteers make home visits to assess how to effectively help such patients. During one visit, GMT volunteers and physicians were so moved by a patient’s crippling vision loss that they refused to be passive observers of his condition. Two undergraduate students spearheaded an international collaboration, called Funds for Felix, to raise money for a surgery to salvage what was left of this patient’s vision. However, several months after the initiation of Funds for Felix, volunteers learned the patient dramatized the circumstances leading to his vision loss. After thorough review of the patient’s predicament, Funds for Felix decided to continue supporting the patient and his family. Though it was ultimately discovered that ophthalmological intervention for this patient would be futile, Funds for Felix helped him enroll at a Braille school in the Matagalpa region of Nicaragua so he could learn how to read. Through constructing a collaborative team spanning national borders, this multidisciplinary group significantly improved this patient’s self-esteem and instilled in him hope for a more fulfilling life.

The Ethical Dimensions of Focusing Global Health Efforts on a Single Patient: an Examination of “Funds for Felix”

·

This article analyzes the ethical considerations involved in focusing a global health effort on a single patient. The specific case considered is “Funds for Felix”, in which money was raised by students for a patient encountered by the UCLA Global Medical Training trip to Nicaragua in December of 2010. As the leader of the UCLA campus branch of Global Medical Training, I approach this case from a broader, organizational perspective. Although the Global Medical Training at UCLA leadership body was enthusiastic about the Funds for Felix project, we wondered about the potential ethical concerns that arise from devoting so many resources to an individual. Ultimately, the approach taken for the Funds for Felix project was extremely successful. This was due to several factors, including the transparency with which the project was conducted, the involvement of Nicaraguan mentors, and the students’ altruistic motivations. Given the rising awareness of global health issues, the relevant ethical questions of the Funds for Felix project are salient for any student or physician in the field of global health.

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