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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

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slide1

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

disclosure
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."

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

educational benefits of international health electives
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 electives6
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
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
is international medical work ethical
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

principles of an ethical international trip
Principles of an ethical international trip
  • Mission
  • Collaboration
  • Education
  • Service
  • Teamwork
  • Sustainability
  • Evaluation
what is chimps
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
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
Principles of an ethical trip
  • Mission
  • Collaboration
  • Education
  • Service
  • Teamwork
  • Sustainability
  • Evaluation
chimps mission
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 trip14
Principles of an ethical trip
  • Mission
  • Collaboration
  • Education
  • Service
  • Teamwork
  • Sustainability
  • Evaluation
enlace
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 trip16
Principles of an ethical trip
  • Mission
  • Collaboration
  • Education
  • Service
  • Teamwork
  • Sustainability
  • Evaluation
educating ourselves
Educating ourselves
  • Sociopolitical context
  • The community
  • Medical Spanish
  • Local medical problems
  • Effective interventions
where do we go
Where do we go?

Los Abelines

los abelines community profile
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 ourselves21
Educating ourselves
  • Understand local medical problems
      • Dental health
      • Intestinal parasites
      • Nutrition
researching effective interventions
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

educating others
Educating others
  • The community
    • Health talks (“charlas”)
  • Our peers
    • Publications, speaking opportunities, etc.
principles of an ethical trip24
Principles of an ethical trip
  • Mission
  • Collaboration
  • Education
  • Service
  • Teamwork
  • Sustainability
  • Evaluation
service doing work that the community needs and wants
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
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
slide29

Things we can treat…

Tooth abscess

Impetigo

Scabies

public health interventions
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
principles of an ethical trip37
Principles of an ethical trip
  • Mission
  • Collaboration
  • Education
  • Service
  • Teamwork
  • Sustainability
  • Evaluation
teamwork
Teamwork
  • Our medical education model:
slide39

The Original Dream Team,

CHIMPS 2003

CHIMPS 2004

slide40

CHIMPS 2005

CHIMPS 2006

principles of an ethical trip41
Principles of an ethical trip:
  • Mission
  • Collaboration
  • Education
  • Service
  • Teamwork
  • Sustainability
  • Evaluation
sustainability building capacity
Sustainability = building capacity
  • Working in a single location
  • “Teaching the Teachers”
  • Augmenting existing systems of care
  • Respecting cultural norms
principles of an ethical trip43
Principles of an ethical trip:
  • Mission
  • Collaboration
  • Education
  • Service
  • Teamwork
  • Sustainability
  • Evaluation
evaluation
Evaluation
  • Needs assessment
    • Identify areas for intervention
  • Clinical studies
    • Define extent of problem
    • Determine efficacy of interventions
iron deficiency assessment
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
challenges
Challenges
  • Overwhelming need
  • Impact on other cultures, economies, and environments
  • Sustainability
  • Access and Equity
  • Meeting expectations
  • Logistics
impact on other cultures economies and environments
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
slide48

Foot bridge project in

Los Abelines, 2005

Total cost: $10,000

sustainability
Sustainability
  • Personnel
  • Resources
  • Institutional support
    • Hospital and University
    • Department of Global Health
  • Partnerships
    • Puget Sound Partners for Global Health
access and equity
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
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
Summary
  • Child health is a global responsibility!
  • Short-term international trips can be done ethically.
  • CHIMPS provides a model for international initiatives that can be replicated at other residency programs.
the pediatrician s gift
The Pediatrician’s Gift

-- To touch the life of a child…

references
References
  • Bezruchka S. Medical tourism as medical harm to the third world. Wilderness & Environ Med. 2000;11:77-8.
  • Emanuel EJ, et al. What makes clinical research in developing countries ethical? The benchmarks of ethical research. JID. 2004;189:930-7.
  • Federico SG, et al. A successful international child health elective. Arch Pediatr Adolesc Med. 2006;160:191-196.
  • Fort M, Mercer MA, Gish O ed. Sickness and Wealth: The corporate assault on global health. South End Press, 2004.
  • Gupta AR, Wells CK, et al. The international health program: the fifteen-year experience with Yale University’s internal medicine residency program. Am J Trop Med Hyg. 1999;61:1019-23
  • Kasper J. Peditricians and the rights of the child. Ped Annals. 2004;33(10):712-5.
  • Marinho V, et al. Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical fluoride for preventing dental caries in children and adolescents. Cochrane Database of Syst Rev. 2004;Issue 1.
  • O’Lorcain P, et al. The public health importance of Ascaris lumbricoides. Parasitology. 2000;121:S51-71.
  • Staton D, Harding M. Protecting child health worldwide. Ped Annals. 2004;33(10):647-55.
  • Thompson MJ, Huntington MK, et al. Educational effects of international health electives on US and Canadian medical students and residents: a literature review. Academic Med. 2003;78(3):342-47.
  • Walsh DS. A framework for short-term humanitarian health care projects. Inter nursing review. 2004;51:23-6.
  • Yip R. Iron supplementation: Country level experiences and lessons learned. J Nutr. 2002;132:859S-861.