Transcript Best Practices and Medical Missions

BEST PRACTICES AND MEDICAL
MISSIONS
Peter Yorgin, MD
No Disclosures
Friday, November 12, 2010
2:00-2:50 PM
GOD’S WORK DONE GODS WAY!
STANDARDS OF EXCELLENCE IN SHORT
TERM MISSIONS
God Centeredness
 Empowering Partnerships
 Mutual Design
 Comprehensive Administration
 Qualified Leadership
 Appropriate Training
 Thorough Follow-up

http://www.stmstandards.org/standards/
Thanks to Rick Donlon, MD
CHRISTIAN HEALTH MISSIONS BEST
PRACTICE
Began with Biblical Standards and Ethics +
Utilized World Health Organization Guidelines
 Wrote consensus documents dealing with:
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Guiding Ethics
Integration with United States Standards of
Excellence in Short-term Missions
 Establishing Effective Health/Medical Partnerships
 Partnerships that Avoid Dependency
 Obtaining Permission to Practice in Another Country
 Bribery
 Energy-based Therapeutics
 Preparation to Serve

CHRISTIAN HEALTH MISSIONS BEST
PRACTICE

Safe Use of Medications
Expired Medications
 Experimental medications
 Medication Use In Clinical Care Settings
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Effective Clinical Care Operations
Surgical Care
 Informed Consent
 Malpractice
 Interpreters
 Medical Records
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Towards Sustainable Short-term Missions
PREPARATION TO SERVE: SIX GROUPS
1.
2.
3.
4.
5.
6.
Partner
People
Local Church
Government
Local health professionals
Christian NGO’s
Note your paper color!
PARTNER: KEY COMPONENTS
Common vision
 Common values
 Holding each others best interest at heart
 Competence
 Reliability
 Faithfulness
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PARTNER
Evaluate assets and needs
 Determine if we are engaging in wholistic healing
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Physical
Spiritual
Emotional
Determine major collaborative health work
 Curative
 Screening
 Prevention/Health Maintenance
 Education
 Surveys
PARTNER
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Due Diligence
 Partner must be engaged in health ministry,
curative care, health development or
education.
 Good pattern of communication.
 Transparency regarding financial issues.
 Questions
Is our partner working in the country legally?
 What are the health needs to which we will be
responding?
 Where does the population currently receive health
care?
 If we chose a curative medical approach, does our
partner have the capacity and resources to provide
follow-up for the people we treat?
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SIX GROUPS
1.
2.
3.
4.
5.
6.
Partner
People
Local Church
Government
Local health professionals
Christian NGO’s
SET!
PEOPLE
 Are
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we providing
Relief?
Rehabilitation?
Development?
 We
should try to work collaboratively with
the people to create a bi-directional
healing relationship that honors God!
SIX GROUPS
1.
2.
3.
4.
5.
6.
Partner
People
Local Church
Government
Local health professionals
Christian NGO’s
SIX GROUPS
1.
2.
3.
4.
5.
6.
Partner
People
Local Church
Government
Local health professionals
Christian NGO’s
SIX GROUPS
1.
2.
3.
4.
5.
6.
Partner
People
Local Church
Government
Local health professionals
Christian NGO’s
SIX GROUPS
1.
2.
3.
4.
5.
6.
Partner
People
Local Church
Government
Local health professionals
Christian NGO’s
SKIT
 In
each of the cases you are people (Some
who are Christians – some not) who are
hosting this team.
 The team is entering the country
 Think about your perceptions as the:
1. Partner
2. People
3. Local Church
4. Government
5. Local health professionals
WHAT ARE YOUR PERCEPTIONS?
1.
2.
3.
4.
5.
6.
Partner
People
Local Church
Government
Local health professionals
Christian NGO’s
Thanks to Brad Warrady, MD
OBTAINING PERMISSION TO PRACTICE IN
ANOTHER COUNTRY

Point of View: Obtaining permission to
practice in another country takes too much
time and is too difficult.
OBTAINING PERMISSION TO PRACTICE IN
ANOTHER COUNTRY
A local doctor arrested this month in
Zimbabwe on charges of practicing without
a license during a mission trip was released
this week, say officials…The pair had been
relieved of their passports approximately two
weeks ago while on a medical mission trip in the
African country... A retired urologist, Dr.
Montgomery and his wife had participated in
several other medical missions around the world.
 http://www.zimbabwesituation.com/jul22_2004.ht
ml
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OBTAINING PERMISSION TO PRACTICE IN
ANOTHER COUNTRY
Romans 13:3
For rulers hold no terror for those who do right,
but for those who do wrong. Do you want to be
free from fear of the one in authority? Then do
what is right and he will commend you.
 Issues of reciprocity.
 Permission is relatively easy to obtain in most
countries – but it takes time.
 International Association of Medical Regulatory
Authorities Countries List.
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http://www.iamra.com/iamra.asp
BRIBERY

Ecclesiastes 7:7
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Deuteronomy 17:1
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Extortion turns a wise man into a fool, and a bribe corrupts
the heart.
… instructs judges: Do not pervert justice or show
partiality. Do not accept a bribe, for a bribe blinds the eyes
of the wise and twists the words of the righteous.
Point of View: Don’t force your culture on others
Virtually every nation of the world has laws prohibiting
bribery.
 Bribery does not fit culturally-influenced morality

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Culturally influenced expressions of universal.
Matters of conscience
BRIBERY

Point of View: Do it for the greater good
Pragmatism is placed over obedience
 The Bible does not have a hierarchy where some
commandments can be broken when the need arises.
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Point of View: Don't think of it as a bribe; think
of it as a gift, or a tip, or a donation.
A gift is given in the context of a relationship to express a
feeling. Where no relationship is present, a gift appears out
of place.
 A bribe, however, is not an expression of relationship; it is
an attempt to exploit a person for selfish gain.
 A gift may be given secretly—perhaps out of modesty—but
secrecy is unnecessary. Without secrecy a bribe brings
disgrace and possible legal consequences.

BRIBERY

Point of View: Bribery Doesn't Hurt Anything.

Bribery is one of the major factors preventing economic,
political, and social development and is inversely
correlated with development. See
http://www.transparency.org/policy_research/surveys_indic
es/cpi/2010/results
EXPIRED MEDICATIONS

Argument: Drugs are safe and potent past their
expiration date so they can be used in other
countries.
The Department of Defense and FDA evaluated the shelf
life of 96 different drugs that were stored in US military
facilities.
 Based on testing and stability assessment, 88% of the lots
were extended at least 1 year beyond their original
expiration date for an average extension of 66 months, but
the additional stability period was highly variable.
 The authors concluded that many drug products, if
properly stored, can be extended past the expiration date;
yet, the stability and quality of extended drug products can
only be assured by periodic testing and systematic
evaluation of each lot.

EXPIRED MEDICATIONS
September 29, 1978, pharmaceutical
manufacturers in the United States had to place
expiration dates on all prescriptions.
 Medications used prior to the expiration date are
generally stable.
 Retail pharmacists place a "beyond-use" date on
all prescriptions, which is generally one year
from the date the prescription is filled.
 WHO GUIDELINES FOR DRUG DONATION
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
6) After arrival in the recipient country all donated
drugs should have a remaining shelf-life of at least
one year.
http://whqlibdoc.who.int/hq/1999/who_edm_par_99.4.pdf
WHO SIGNED-ON TO THE WHO
GUIDELINES FOR DRUG DONATION?
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World Health Organization
Caritas Internationalis (Catholic)
Churches’ Action for Health of the World Council of Churches
International Committee of the Red Cross
International Federation of Red Cross and Red Crescent
Societies
International Pharmaceutical Federation
Joint United Nations Programme on HIV/AIDS
Médecins Sans Frontières
Office of the United Nations High Commissioner for Refugees
OXFAM
Pharmaciens Sans Frontières
United Nations Children’s Fund
United Nations Development Programme
United Nations Population Fund
World Bank
WHAT WERE THE CORE PRINCIPLES OF THE
WHO GUIDELINES ON DONATED DRUGS?
1.
2.
3.
4.
Maximum benefit to the recipient
Respect for wishes and authority of the
recipient
No double standards in quality
Effective communication between donor and
recipient
DONATED MEDICATIONS FROM HOME AND
SAMPLE MEDICATIONS
Point of View: Donated unused prescriptions
helps teams to provide no-cost medications
 There can be problems with the storage
conditions of dispensed prescriptions:

Heat and humidity,
 Changing (older or another) medication from one
bottle to another
 Rough handling (so that parts of tablets have turned
to powder), or
 Outright contamination.


Confirmation of drug name, dose, storage
condition and stability is likely to be beyond the
scope of a short-term healthcare mission team.
DONATED MEDICATIONS FROM HOME AND
SAMPLE MEDICATIONS
Point of View: Medication samples are a no
cost way to provide medications to people in
need.
 Type of medications
 Packaging
 Black Box Warnings: Of the fifteen most
frequently distributed free medication samples,
four received new or revised black box warning,
indicating that the medication is not be as safe as
thought or can even cause death.

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Cutrona, S.L. et al. Free drug samples in the United
States: characteristics of pediatric recipients and safety
concerns. Pediatrics 122, 736-42 (2008).
DONATED MEDICATIONS FROM HOME AND
SAMPLE MEDICATIONS

Many medications have been released for
treatment of conditions before their safety and
adverse effect profile is fully understood.
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Lasser, K.E. et al. Timing of new black box warnings
and withdrawals for prescription medications. Jama
287, 2215-20 (2002).
Issa, A.M. et al. Drug withdrawals in the United States:
a systematic review of the evidence and analysis of
trends. Curr Drug Saf 2, 177-85 (2007).
WHO GUIDELINES FOR DRUG DONATION
4.
No drugs should be donated that have been
issued to patients and then returned to a
pharmacy or elsewhere, or were given to health
professionals as free samples.
http://whqlibdoc.who.int/hq/1999/who_edm_par_99.4.pdf
http://www.who.int/medicines/publications/essentialmedicines/en/index.html
BEST PRACTICES FOR SAFE MEDICATION
USE
Local medications
 Make sure to obtain an adequate history with
medication allergies, a good examination and any
laboratory or imaging studies as needed
 Give important information about the medication
to the patient

Labeled in the local language – medication, dose, and
prescription.
 What the medication does, potential adverse effects,
what to do if the medication does not work
 Site for follow-up
 Risks associated with overdose
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BEST PRACTICES FOR SAFE MEDICATION
USE
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Use medications that have a high benefit:adverse
risk ratio.
Minimize use of NSAIDS
 Avoid cold preparations for children less than 6 years
of age.
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Consider our role in distributing chronic
medications like:
Oral hypoglycemics
 Antihypertensive medications
 Lipid lowering agents

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Use of experimental medications is beyond the
scope of a short-term medical team.
SURGERY
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Surgical teams can be a great blessing
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Only perform procedures that you do at home
Plan to do less than you normally do at home
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Share your knowledge with other physicians
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Cochlear implant project
Great chance for surgical CME – sharing new knowledge
WHO Surgical Guidelines:
http://www.who.int/topics/surgery/en/
Emergency Surgical Care


Translation
Education takes time
http://www.who.int/surgery/publications/imeesc/en/index.ht
ml
Emergency Surgical Care in Disaster Situations

http://www.who.int/surgery/publications/BestPracticeGuide
linesonESCinDisasters.pdf
INFORMED CONSENT

The UNESCO Universal Declaration on Bioethics
and Human Rights (October 19, 2005) Acticle 6.1
states:

Any preventive, diagnostic and therapeutic medical
intervention is only to be carried out with the prior,
free and informed consent of the person concerned,
based on adequate information. The consent should,
where appropriate, be express and may be withdrawn
by the person concerned at any time and for any
reason without disadvantage or prejudice.
http://unesdoc.unesco.org/images/0014/001461/146180e
.pdf
INFORMED CONSENT
1.
2.
3.
4.
5.
6.
7.
Pray and seek God’s wisdom, discernment and
permission prior to any consent.
Written consents are probably better.
The consent should be in the language of the
person who is undergoing the procedure.
The name of the healthcare professional
performing a procedure.
The organization to which the surgeon belongs.
Provide basic information about the problem
Explain what is being done – in layman’s terms
INFORMED CONSENT
8.
Review the risks
1.
No guarantees
Have a understanding of alternative treatment
options
Give a recommendation from the medical team
Assure that she/he has the right to refuse If
refused, care will still be provided.
Provide a signature or mark or verbal
agreement indicating their agreement.
Pray
2.
9.
10.
11.
12.
13.
Make sure that the patient is familiar with the concept
of risk/chance
FINAL THOUGHTS

Local first
Challenges with cross-cultural service
 Cross-cultural health ministry can be done
successfully

It is not the stuff that we bring – it is the
relationship with Christ that we bring
 Authentic broken follower of Christ
 Look to and Praise God for healing
 Tea time

GOD’S WORK
DONE GOD’S WAY?
THANKS!
HTTP://CSTHMBESTPRACTICES.ORG
THE CENTER FOR THE STUDY OF
HEALTH IN MISSIONS
PDF DOCUMENTS AVAILABLE
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