At only 5.5 pounds (10 pounds less than the fifth percentile for weight on the World Health Organization’s growth chart), an 8-month-old boy suffered from severe malnutrition. In the summer of 2003, amidst the height of Liberia’s civil war, his aunt brought him to the Médecins Sans Frontières/Doctors Without Borders hospital for treatment. Because of the war, his family had been forced to flee from their home, leaving behind their usual methods of getting food. Dr. Andrew Schechtman was there to help the day the child was brought to the clinic in Liberia (Figure 6-1). Despite the best available treatment for the malnutrition and concurrent pneumonia, the boy died on his third hospital day.

Those of us who become pediatricians or other health care providers do so for many reasons. One reason is because of a desire to help someone else. Along the way, we sometimes lose ourselves in the day-to-day struggles, disappointments, obligations, fatigue, and the profound helplessness that descends upon us after a particularly bad day. But we are still here, and if we listen with our hearts we are still capable of great and small things.

We are privileged in so many ways and we must recognize our power over ourselves and over the communities that we serve. It is easy to become overwhelmed by the problems that we face as clinicians and as fellow human beings. Our health care system is in shambles, our natural world is being poisoned, our nations are continually at war, and yet, as this chapter highlights, there is so much that we can do—we can listen, we can observe, we can witness, we can bring aid, we can touch, we can love, and we can lead.

The text that follows highlights just a few examples of the ways in which our colleagues are challenging themselves to find creative solutions to the many problems faced by those who are underserved, displaced, or suffering.

Epidemiology

The United Nations (UN) High Commissioner for Refugees reported that in 2011 there were 10.9 million refugees (those displaced across an international border) and 27.5 million internally displaced persons (IDPs, those displaced within their own country).¹ At the end of 2010, the UN refugee agency was caring for an estimated 14.7 million of these IDPs. During times of a complex humanitarian emergency (defined as a humanitarian crisis in a country, region, or society where there is a breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single agency and/or the ongoing UN country program), the following usually occur:²

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  Civilian casualties.

  
  
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  Populations besieged or displaced.

  
  
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  Serious political or conflict-related impediments to delivery of assistance.

  
  
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  Inability of people to pursue normal social, political, or economic activities.

  
  
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  High security risks for relief workers.

Etiology

People can be displaced from their homes by manmade (war or persecution) or natural disasters (tsunami, earthquake, or hurricane). War is responsible for most of the displacement. Some of the source countries accounting for the most refugees are Afghanistan, Sudan, Somalia, the Palestinian territories, and Iraq.

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  Communicable diseases usually cause the most illness and deaths in humanitarian emergencies in less-developed countries. Children younger than 5 years of age are the most vulnerable.² Other priority areas include provision of adequate safe water, food, shelter, and protection from violence.

  
  
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  In addition to the usual causes of illness and death in emergency-affected populations in less-developed countries (measles, malaria, pneumonia, and diarrhea), crowded settlements may be prone to outbreaks of cholera, meningitis, and other diseases, which can be rapidly spread. Such outbreaks may be explosive and cause many deaths in a relatively short period of time.

Problem Identified

In times of stability, writes Dr. Andrew Schechtman, many of the poorest people in the world succeed in their struggle to meet basic needs for shelter, food, and water. When displaced from their homes by manmade or natural disaster, communities and extended families are disrupted, access to food and water are lost, and marginal circumstances become desperate. Displaced people are often dependent on the support of the international aid community to meet their basic needs.

Being Part of the Solution

When infrastructure collapses as a result of manmade or natural disasters, access to health care can be limited or nonexistent. Serving as a volunteer physician with Médecins Sans Frontières (Doctors Without Borders) allowed Dr. Schechtman to provide medical care to people in desperate circumstances who had nowhere else to turn for assistance. Bearing witness to tragedies such as the case described in Figure 6-1 gave him another means to help, that is, the authority to speak out on behalf of victims like this child, focus public attention on the situation, and encourage political pressure to bring the fighting to an end.

Epidemiology

Global health can be defined as the health of populations, which transcends national and international borders. As such, global health involves the perspectives of economics, epidemiology, medicine, public health, and many of the social sciences for measuring, understanding, and providing care to improve health and achieve equity in health for all people. The health issues faced on a global scale are staggering. Worldwide, one billion people lack access to health care systems.³ Non-communicable diseases such as cardiovascular disease, cancer, chronic lung disease, and diabetes cause about 36 million deaths per year, and communicable diseases including AIDS/HIV, tuberculosis, malaria, and measles cause about 6.7 million deaths annually. Over 7.5 million children under the age of 5 years die from malnutrition and mostly preventable diseases each year.³

Global health experiences can complement and enhance physician training in many ways. For the student, these experiences can bring new interpersonal and technical skills, teach cultural competency, and enhance their knowledge base about health issues faced by their host country and management of many of these health problems. Students express great interest in these experiences. In a survey of medical students at Sanford School of Medicine, University of South Dakota, almost 95 percent of students indicated they were either very interested or somewhat interested in serving internationally during medical school or later during their career.⁴ Following these experiences, students report having greater clinical skills, being more culturally competent, and are more likely to choose a primary care specialty and/or a public service career.^5,6

Etiology

Peru, as the host country, is a nation of 29,988,000 people. The gross national income per capita is $9,440, making it one of the poorest nations in the region. Peru’s total per capita expenditure on health also falls far below its neighbors, by nearly tenfold, and the health workforce of 9.2 physicians per 10,000 population and 12.7 nurses and midwives per 10,000 population is inadequate to meet the nation’s health care needs. Based on the World Health Organization database, more people die of communicable disease in Peru than the regional average (37% versus 20%, 2008 data) and the probability of dying under age 5 years, although greatly improved since 1990 is 18/1000 live births, similar to the regional average. Communicable diseases such as infectious diarrhea, tuberculosis, hepatitis, dengue fever, and typhoid fever are widely seen, and malaria, bartonellosis, leishmaniasis, and yellow fever are endemic in specific areas of the country. All are potentially preventable through vaccinations and preventive health measures.

As global citizens, we can’t ignore these health issues, particularly those of us in wealthier nations living in relative affluence. The brave among us actively work for change. While many schools offer global health experiences, the challenge to educators in the academic institution, medical care providers in the host country, and policy makers is to create regulatory frameworks and curricula that are current and relevant.⁸ This requires a level of understanding of globalization on medical education, and the underlying ethical, cultural, and health issues to prepare students for the planned experience and to practice competently in a globalized world. The following should be considered in creating global health electives for medical students or residents:

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  Balancing the provision of a fulfilling educational experience with honoring the integrity of medically underserved populations.⁹

  
  
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  Offering training that is appropriate for the educational level of the learner, and different types of training for the types of physicians preparing to work in the global health community—the “globalized doctor,” “humanitarian doctor,” and the “policy doctor.”¹⁰

  
  
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  Taking the time to observe and study the structure and function of the health care delivery system in the host country.

  
  
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  Considering the safety of the health team, travel and lodging, and adequately preparing them prior to going to the host country on the nature of the host country culture, health care system, and assignment site.¹¹

  
  
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  Securing financial support.

  
  
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  Preparing participating faculty members, who may have limited experience, to enable them to support and guide students during their global experience.

Problem Identified

Dr. Krishna’s involvement in “global health” began when, as a medical student in India, she witnessed a cholera epidemic in the neighboring country of Bangladesh. Overnight there was an influx of sick, dehydrated refugees at the doorsteps of the hospital where she was training. Intravenous lines were inserted before histories were taken. As the epidemic spread into the local communities, the vaccine fell into short supply and populations at risk received only one dose instead of the 2 recommended doses of Cholera vaccine. This left her with many unanswered questions regarding the efficacy of a single vaccine dose, the ethics of “good enough,” and how to dive into such issues when the opportunity arose. Now on staff at the Cleveland Clinic, Dr. Krishna had the opportunity to participate in and subsequently direct the Peru Health Outreach Project (PHOP), a formal elective for medical students at her institution.

Being Part of the Solution

The PHOP was started in 2007 by four medical students at the Lerner College of Medicine (Cleveland Clinic) and Case Western Reserve University School of Medicine. The mission of this student-led staff-mentored project is to collaborate with health care professionals in Peru to provide ethical and sustainable medical care to the underserved in the Sacred Valley of Peru. Since inception, it has continued to grow exponentially due to student interest and participation. Students participate in clinics; vision screening; well child checks (Figures 6-2 and 6-3); diabetes screening; counseling regarding hygiene including dental, lifestyle modifications, healthy diet; prophylaxis for Vitamin A deficiency (Figure 6-4); and research. In collaboration with physicians in Peru, the students also organize and hold a 2-day educational symposium for local health care workers. Speakers have included staff members and students with topics ranging from CPR to recognition of high-risk pregnancies and common respiratory illnesses in children.

Students continue to provide very positive feedback from this elective. As one student wrote, “I learned a great deal about cross-cultural communication and humility. In terms of global health, I’ve learned that there’s a lot that needs fixing out in the world, particularly in the Sacred Valley of Peru, and that we need to search for a sustainable mechanism to help that involves and empowers the local residents to take charge of their own health and that of their neighbors. In terms of leadership, I’ve learned a lot about working with a team of people from all different backgrounds toward a common goal. I’ve learned that it can be extremely challenging at times but that the best way to come to a compromise is to encourage and use effective communication. Overall, I would say the Peru Trip has been one of the greatest learning experiences for me during my first two years of medical school, teaching me lessons I will take with me through the rest of my career and life. It has been truly life-changing.”—Andrea Grosz, Case Western Reserve University School of Medicine, class of 2014.