Building Sustainability through Brief International Projects: Lessons Learned from a Resident-Run Program

1. Building Sustainability through Brief International Projects: Lessons Learned from a Resident-Run Program Parmi Suchdev, MD, MPH Epidemic Intelligence Service Officer Centers for Disease Control & Prevention Kelly Evans, MD Pediatrics Resident University of Washington AAP Resident Section Annual Assembly October 7, 2006 CHIMPS

2. Disclosure • “We have no relevant financial relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.” • “We do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.” "The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy."

3. Objectives • Overview of international health training in residency • Ethical principles for short-term trips • CHIMPS as a model • Challenges • Resources

4. 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! 2Thompson, et al.Academic Medicine, 2003. 1AAMC, 2000

5. 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.

6. 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.

7. 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

8. 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 promote the U.S. model of “damage care” or to build equitable public health structures? Bezruchka, Wilderness & Environ Med. 2000

9. Principles of an ethical international trip • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

10. 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

11. 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/

12. Principles of an ethical trip • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

13. CHIMPS’ Mission “To ethically address underlying health issues and to provide sustainable public health interventions and medical assistance for underserved communities in developing countries.”

14. Principles of an ethical trip • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

15. 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/

16. Principles of an ethical trip • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

17. Educating ourselves • Sociopolitical context • The community • Medical Spanish • Local medical problems • Effective interventions

18. Where do we go? Los Abelines

19. The Official Summary of The State of the World's Children, UNICEF, 2004.

20. 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%

21. Educating ourselves • Understand local medical problems • Dental health • Intestinal parasites • Nutrition

22. Researching effective interventions • Fluoride varnish1 • Reduces caries • Effect most pronounced if no other fluoride source • Empiric periodic deparasitization2 • Every 6 month treatment reduces ascaris infection • Ascaris = major contributor to malnutrition and anemia • Iron supplements3 • 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 2O’Lorcain, Parasitology. 2000 3Yip, J Nutr. 2002 1Marinho, Cochrane Database. 2005

23. Educating others • The community • Health talks (“charlas”) • Our peers • Publications, speaking opportunities, etc.

24. Principles of an ethical trip • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

25. Service: “Doing work that the community needs and wants” • Clinical medical care • Linking the community with the local physician • Public health interventions

26. 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

27. Bienvenidos a la clinica!

28. Gathering health statistics

29. Things we can treat… Tooth abscess Impetigo Scabies

30. The difficult cases we can’t…

31. Public health interventions • Dental Health • Education (“charlas”) • Toothbrushes • Fluoride varnish 3 times/year • Intestinal Parasites • Charlas • Empiric treatment 2-3 times per year • Complement community efforts to build latrines, provide clean water • Nutrition • Charlas • Iron supplementation • Community garden

32. Applying fluoride varnish Now you try it

33. Best brusher competition…

34. “Teaching the teacher”

35. Building confidence

36. Charlas in action

37. Principles of an ethical trip • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

38. Teamwork • Our medical education model:

39. The Original Dream Team, CHIMPS 2003 CHIMPS 2004

40. CHIMPS 2005 CHIMPS 2006

41. Principles of an ethical trip: • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

42. Sustainability = building capacity • Working in a single location • “Teaching the Teachers” • Augmenting existing systems of care • Respecting cultural norms

43. Principles of an ethical trip: • Mission • Collaboration • Education • Service • Teamwork • Sustainability • Evaluation

44. Evaluation • Needs assessment • Identify areas for intervention • Clinical studies • Define extent of problem • Determine efficacy of interventions

45. 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

46. Challenges • Overwhelming need • Impact on other cultures, economies, and environments • Sustainability • Access and Equity • Meeting expectations • Logistics

47. 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

48. Foot bridge project in Los Abelines, 2005 Total cost: $10,000

49. Sustainability • Personnel • Resources • Institutional support • Hospital and University • Department of Global Health • Partnerships • Puget Sound Partners for Global Health

50. 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