Friday, October 1, 2010

The Challenge of Global Health and Primary Care

I recently attended the 7th American Academy of Family Physicians (AAFP) sponsored Family Medicine Global Health Workshop. Over a period of 3 days, we heard plenary speakers, attended small-group breakout sessions, reviewed a large number of posters, and had an opportunity to talk and share ideas with each other. As one of those in attendance with the least experience in international health (while I have spent some time in Brazil, including a rather short teaching Fulbright, I have never been part of so much as a “medical mission” trip, not to mention spent protracted or recurrent time in providing health care or developing health systems in other countries, either in disaster relief or ongoing care), I felt I had a great deal to learn and I tried hard to absorb as much as possible. The collective experience represented by the attendees was overwhelming. Senior participants had spent decades working in both direct patient care and the creation of clinics as well as in consulting with governments and Ministries of Health on developing health systems based in primary care and family medicine. Some of the participants had returned for years – or for decades – to the same regions, spending months there each year. Family physicians ran or were part of a number of not-for-profit organizations that provided disaster medicine or primary care in countries in need around the world. Others were still residents, or even medical students, who had spent some time in areas of need (most recently, of course, in Haiti) and were planning on making this a central part of their future careers.

There was a breadth of motivations for this work. While many of the participants, and many who work in international health, were inspired by their religious beliefs (and “medical missions” still, in most places including medical schools, is the de facto term for any trip taken by physicians and students even when not sponsored by a religious organization), there were others whose motivation was not, and in particular was social justice. A poster presented by Joanie Baumer, MD, from Fort Worth’s John Peter Smith Hospital Family Medicine Residency (the largest in the country), which has been involved in programs in many countries, surveyed participants on what their main motivations were – and what they perceived those of others to be. Social justice topped the both lists, with “mission” (religious) about 4th, although it was higher in motivations attributed to others.

Plenary sessions from former HHS Secretary and University of Miami President Donna Shalala and others addressed important issues. Fitzhugh Mullan, MD, of George Washington University raised the issue of “brain drain” (see also Primary Care, IMGs, and the Health of the People in this blog, August 14, 2010), in which physicians trained in developing countries, often at public expense, migrated to wealthy Western countries, where they were often welcomed (as in the US) to fill residency and underserved-area-practice positions. While there was some pushback from the (small number) of attendees who had come to the US from other countries, it is hard to argue with Dr. Mullan’s proposition that “the US ought to be able to train enough physicians to care for its population without having to import them from the developing world” (paraphrased). As in so much of policy, there is often a distinction between the individual stories, needs and aspirations of individuals and the overall effect. Cynthia Haq, MD, of the University of Wisconsin, told her own story; one of increasing involvement in international work, from naïve trips to longer stays, to work with WHO and helping other countries develop their health systems, seamlessly intertwined with the story of her own family (“Stepping Stones: Strategies to enrich your life with Global Family Medicine”, posted like many of the other presentations, to the Family Medicine Digital Resource Library, Steven Spann, MD, of Baylor, presented a superb discussion of ethical issues in doing international work. In a breakout session (and remember, I can only report on those I attended) Gary Morsch, MD, founder of Heart to Heart International, presented the work of that group, which provides opportunities for health professionals to work abroad for shorter periods, a week or two, in settings such as Haiti, in contrast to larger and more famous organizations such as Medecins sans Frontieres, which requires 6-9 month commitments. Dr. Morsch also described H2H’s affiliated group, “Docs Who Care”, which provides locums tenens opportunities in rural parts of the Midwest, both helping those communities with their health needs and the physicians with the opportunity to earn a living in a manner that allows them to spend much of their time doing international work.

Haiti, where the January 2010 earthquake created incredible needs in a nation already living on the edge, with over 300,000 killed outright and hundreds of thousands more severely injured physically, psychologically, and emotionally as well as having every aspect of their lives disrupted or destroyed, was obviously a major focus. Many of the presenters of posters and breakout sessions, and many more of the attendees, had spent some time working in Haiti, in the initial “disaster” phase or the (still disastrous) “primary care” phase. They discussed the good (the people and their resilience, the commitment of the volunteers, the resources pouring in) and the not so good (the historical background of oppression and de-resourcing of Haiti, the lack of coordination between relief agencies, the volunteers who were on occasion self-centered and more often ignorant of the needs and realities of the situation). One of the best sessions I attended was by André Vulcain and Michèle Dodard of the University of Miami Department of Family Medicine. In 1999, they helped to start a family medicine residency program in Haiti’s second city, Cap Haitien, which had graduated 35 family physicians by the time of the quake and is still functioning. Unlike many of the other collaborations described, which are often with private (usually religious) hospitals, this program is sponsored by the Ministry of Health of Haiti and is based in a government hospital. While Dr. Vulcain’s powerpoints are not yet available on FMDRL, Dr. Dodard’s description of the work of the University of Miami’s “Project MediShare”, Rebuilding Haiti’s Healthcare System, is. Rebuilding that system, working with the Haitian government and people, training Haitian health professionals so that they do not need to depend on “mission trips” has also become a key focus of the work of Partners in Health (PIH) (“Zanmi Lasante” in Haitian Kreyol) and many other groups.

One of PIH’s founders, Paul Farmer MD PhD, and his colleagues Vanessa Bradford Kerry MD and Sara Auld MD propose the creation of an “International Service Corps for Health” in an article in a the September 23, 2010 issue of the New England Journal of Medicine.[1] They talk about the work that has been done, particularly that done by academic medical centers, but also address the limitations, especially financial, of these efforts, and suggest that a government-sponsored program, working in collaboration with other US agencies, might be a very effective way of increasing the international reputation of the US as well as helping to meet the staggering needs that exist in the world, such as in Africa, which “…bears 24% of the global disease burden but hosts only 3% of the global health care workforce and is responsible for less than 1% of world health care expenditures.” They describe the enormous impact that the small country of Cuba has had internationally, “…between 1999 and 2004, Cuban foreign-service workers increased doctor visits in resource-poor communities by 36.7 million, provided health promotion outreach for millions of underserved people, and taught 900,000 medical education courses to local personnel.” If carried out reasonably and equitably, an International Health Service Corps (IHSC) might be a major step forward.

There are still great healthcare needs in the US, and very underserved communities (both rural and urban), as detailed in the recent US Census Bureau report “Income, Poverty and Health Insurance Coverage in the United States, 2009”, and it is sometimes distressing to medical educators to observe that many medical students have much greater enthusiasm for “international work” than they they do for helping to meet those domestic needs. However, as Kerry et. al., and the presenters at the AAFP Conference, among others, document, the international needs are staggering.

The interest and commitment of health professionals and students in working internationally, demonstrated not only in the AAFP Global Health Conference but daily in our schools and residency programs, is a wonderful thing. Developing meaningful, useful, and long-term opportunities to serve, such as the existing programs described above and at the conference, or a new “international health service corps”, are very important goals.

[1] Kerry VB, Auld S, Farmer P, “An international service corps for health – an unconventional prescription for diplomacy”, NEJM 2010Sep23;363(13):1199-1201

No comments:

Total Pageviews