Transcript preprd - Department of Family and Community Medicine

Pre-Experience Preparation and
Post-Return Debrief (PREPRD)
Department of Family and Community Medicine
University of Toronto
2012-2013
Objectives
Review the following:
1. Context of global health
2. Health and safety
3. Cross-cultural learning
4. Living and working in LMIC
5. Starting a geo-journal
6. TED talk
7. Discussion around motivations
8. Ethical challenges in global health
9. Return and debrief
Rationale
 Increasing numbers of trainees and faculty are participating
in GH activities
 University of Toronto: Stated goal to increase
international/global experiences for students
DFCM. Global health program: Strategic plan. February 2010.
Rationale
 DFCM Global Health Strategic plan
"Strengthen orientation, pre-departure preparation and
on-site support for faculty and learners undertaking
global health work in partner countries."
 Need for PDT recognized by AFMC, CFMS, CAIR, CFPC
DFCM. Global health program: Strategic plan. February 2010.
DFCM Global Health
Vision: Improving global health and achieving equity by
championing primary health care.
Principles:
 Social justice
 Equity
 Solidarity
 Reciprocity
 Accountability and Responsiveness
 Respect
 Honesty and Humility
http://www.dfcm.utoronto.ca/Assets/DFCM+Digital+Assets/About+Us/2010++GH+Program+Report.pdf
www.wuhs.org
Profiles from the DFCM
• Paul Caulford, Scarborough General Hospital
– Founder of the Volunteer Clinic for the Uninsured
• Samantha Nutt, Women’s College Hospital
– Founder of War Child Canada
• Jane Philpott, Markham Stouffville Hospital
– Founder: Give A Day to World AIDS
1. The Context of Global Health
Electives
Benatar SR. PLoS Medicine 2005; 2(12) e400
“…the goal is not to teach or study global health as a
distinct subject or skill-set. But every topic of medicine
needs to be reconsidered from a global perspective…”
Philpott J. Virtual Mentor 2010; 12(3): 231-236
How family
physicians can
engage in
global health
Pottie K, Redwood-Campbell L, Rouleau K, Ouellette V, Lemire F. Degrees of engagement: Family physicians
and global health. Can Fam Physician. 2007 Nov;53(11):1853-7, 1866-70.
What do we mean by Global Health?
Write down a definition of global health,
using 1-2 sentences.
Global Health
“an area for study, research and practice that
places a priority on improving health and achieving
equity in health for all people worldwide. Global
health emphasizes transnational health issues,
determinants, and solutions; …promotes
inter‐disciplinary collaboration; and is a synthesis of
population‐based prevention with individual-level
clinical care”
Koplan. Lancet 2009.
‘Since many of the causes of global public
health problems arise from imbalances in
power that permit exploitation and
subjugation, our moral obligation to
address the political determinants of
health is inescapable.’
Global Health Watch Report 2. http://www.ghwatch.org/sites/www.ghwatch.org/files/ghw2.pdf
Role of Family Medicine in GH
Countries with strong primary care systems have better health
outcomes and lower healthcare system costs.
"Family physicians are skilled at understanding undifferentiated
illness, social determinants of health, and first-line treatment of
common conditions, so they have much to contribute to primary care
in resource-poor settings."
Starfield B. Is primary care essential? Lancet 1994;344(8930):1129-33.
Redwood-Campbell L, Oulette V, Rouleau K, Pottie K, Lemire F. International health and Canadian family practice. Can Fam
Physician. 2007; 600-602.
2. Health and Safety
Health & Safety
• As with other elective experiences, this is your
responsibility
• Key items:
– Safety Abroad http://www.utoronto.ca/safety.abroad/
– Travel insurance
– Appointment with a travel medicine clinic
– Do your own homework:
http://www.voyage.gc.ca/
http://wwwnc.cdc.gov/travel/
Health and Travel Insurance
 Outside Canada, OHIP coverage is limited.
 Key questions to ask:
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Does the plan include hospitalization coverage for accidents and illnesses while abroad?
Does it cover you for pre-existing medical conditions?
What is the maximum amount of coverage that is provided?
Are there deductibles? If so, what are they?
Will the plan include emergency room expenses? Is the coverage sufficient?
What is the coverage for medical evacuation? Is the coverage sufficient?
In the event of death, what is the coverage for repatriation? Is it sufficient?
Will they cover the costs involving transporting you home if ill?
What information does the Insurance company need prior to payment?
Is there a 24-hour contact number in English (with translation services for health care providers in the Host
country)?
Is dental coverage provided?
Is ambulance or emergency transport to a hospital covered?
When does the plan begin and end? Can you easily extend coverage? While overseas?
What is not coved by your plan? Does this effect you?
http://www.utoronto.ca/safety.abroad/go_global_guide_health.html
Health & Safety
 Specific travel notices and advisories
 E.g. Malawi – measles advisory
 Safety and security
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E.g. Ghana – avoid unnecessary travel
General safety and risk of crime
Civil unrest
Pay attention to areas of concern
 Special precautions for foreigners
 Special precautions for women
 Laws and customs
 E.g. Malawi: "Homosexual activity is illegal"
Health & Safety
 Vaccine-preventable diseases:
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Routine e.g. TDaP, IPV, MMR, meningitis, pneumococcal
Hep A & B
Typhoid
Yellow fever (Rwanda)
Rabies
 Malaria prophylaxis
 NB: Consider side effects and where to obtain replacement if lost/stolen
 Your own medications, prescriptions and MD letter
 Sexually transmitted infections
Health & Safety
 Protection
 Sun protection: long sleeves, hat, sunscreen
 Bug repellent, insect net
 Bed net
 Food and water safety; Water purification tablets
 Allergic reactions and asthma exacerbation
 Be aware of exposure to parasites: water (Lake Malawi),
wet clothes, etc
Health & Safety
Precautions
 Do not travel at night if possible
 Don’t use motorcycles - highest risk: MVC
 Follow the advice of your hosts
 Do not take unnecessary risks, particularly as a "tourist"
Logistics
• Entry and exit requirements: visas, passports
(check date its valid until)
• Photocopy documents:
– Keep one set with you, separate from originals
– Leave one set with emergency contact
– Provide one set to a friend you are travelling with
– You can leave one set with DFCM (kept secure)
• Register (beforehand) with consulate or embassy
Key documents
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Passport + Visa/travel permit
Airplane tickets and travel plan (door-to-door)
Money: credit cards, cash, travellers cheques*
Health insurance card
Prescriptions (medical & eye wear)
Letter of introduction
Emergency contact
Consider scanning and emailing a digital copy to yourself!
Health & Safety: Clinical Work
• Personal Protective Equipment: Check and see what is
available…
– Lab coat
– Eye protection
– Gloves: regular and surgical
– Hand sanitizer
• Post-exposure prophylaxis
– Discuss protocol re: needle-stick injuries
– Consider obtaining an HIV PEP kit
Clinical work: Items to bring
• Essential items:
– Stethoscope
– Flashlight + batteries
– Measuring tape
• Recommended items:
– opthalmoscope/otoscope (convertor!) + caps
– BP cuff
– thermometer (non-mercury)
– tuning forks
– 02 saturation monitor
Clinical work: Resources
 To bring:
 Oxford Handbook of Tropical Medicine
 The best resource is often locally developed treatment
guidelines! (e.g. Malawi)
 Websites:
www.mayo.edu/alumni/ATasteofTropicalMedicine.html
www.pitt.edu/~super1/
globalhealtheducation.org/Modules/SitePages/Home.aspx
 Reference:
 Lecture Notes: Tropical Medicine, Gill & Beeching
 Where There Is No Doctor (for health education purposes)
Clinical work: Teaching
• Teaching can be a great way to provide service and can help with
integration and your own learning
• However, you are generally not the expert – be aware of the
limitations of applying your knowledge in another setting
• Be aware of existing relationships, hierarchy and dynamics between
trainees and staff
• Ask first always and try to work with a colleague to co-teach sessions
• Bring resources from home (handouts, etc)
3. Cross-cultural learning
Cross-Cultural Learning
You read on the Foreign Affairs website:
"As in many African countries, Malawian culture is generally
conservative and respectful of elders. Common sense and
discretion should be exercised in dress and behaviour.
Respect religious beliefs and social conventions to avoid
offending local sensitivities."
What does this mean to you?
What will you do differently?
Cross-Cultural Learning
“The ideas, customs, and social behaviour of a
particular people or society”
www.oxforddictionaries.com
www.aartichapati.com
Culture Shock
The reaction one faces when
confronted with a new cultural
environment; the effect of going from
one culture into another
• Typically worse 3-4 months into the
journey.
Symptoms: sleepiness, irritability,
depression, resentment towards host
society.
Culture Shock
Minimizing the effects of culture shock:
 International awareness
 Cross cultural communication skills and sensitivity
 Prepare: bring stuff from home (photos, music); plan to keep in
touch with friends and family from home
 Be open to the experience
 Keep mentally and physically fit
 Keep a journal
 Keep in mind the traveller’s mantra: “okay, okay”
 Know that if necessary, you can always come home.
4. Living and Working in LMIC
Living and Working in LMIC
Workplace
• As soon as you arrive, or even before you arrive, try to learn
about the culture of the team you will be working on, including:
- office environment and workspace
- transportation (airport pick up/drop off; daily transportation to
workplace; costs for these)
- living arrangements
- protocols for interacting with your supervisor, colleagues and
project partners
- procedures for requesting vacation time
Living and Working in LMIC
Living arrangements and personal space:
 Arrangements (e.g. hostel, guest house, shared vs. individual
accommodation, laundry; costs for these)
 Food and grocery availability; shopping
 Cost of living
 Transportation for personal use and leisure activities
 Power requirements for electrical appliances and computers, rate of power
outages, availability of back up generators
 Speed of internet connection
Phone & Internet
• Bringing a cheap cell phone (that is compatible in your host country)
can be really handy – will likely need to get a SIM card and buy time
• Remember: bring enough power adaptors
• May be able to borrow a cell phone there
• If fast internet connection, Skype is excellent – good idea to call
home once a week
• Be aware of time difference and the challenge of power outages
Professionalism
 Giving money to community members or patients while in the field is often
not appropriate. For donations, check with supervisor.
 Photographs without verbal permission is strongly discouraged. Be cautious
in clinical settings.
 Keep in mind that you are a guest and professional conduct is very
important. Impoliteness can create problems that last long after you leave.
 Image is important and appropriate attire is a must.
 If you are having trouble integrating yourself in the project or community,
speak with someone you trust in your project or your supervisor.
Professionalism
 Drugs: In some countries the widespread use of drugs may
give the impression that such use is tolerated by authorities.
This, however, is never true and the consequences may be
particularly harsh for foreigners (i.e. imprisonment or
deportation).
 Confidentially: Most students and residents are required to
observe Canadian privacy laws, and are bound by ethical
principles of confidentiality. Sensitive information should be
handled with discretion. Many project sites will require
signing of confidentiality agreements.
Professionalism
 Always greet people, then find a place to sit.
 If in doubt, dress up.
 Smile and nod.
 Silence is not consensus.
 Never ignore the hierarchy.
See also: Safety Abroad Manual, University of Toronto
http://www.utoronto.ca/safety.abroad/go_global_guide_shoc
k.html
5. Introducing a Geo-Journal
Key Questions
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Geography of the country you will be working in
Population demographics
Socio-political influence at present
Culture and social customs
Major economic drivers
Languages spoken
Significant health influences on your community
Key Questions
1. Learn some simple phrases such s "hello" and "thank you".
2. What is the current political situation Are there any dangerous areas that you
should avoid?
3. Do Canadians/ foreigners have a good/ bad reputation in the area that you
will be staying in? What are the reasons?
4. What is customary dining etiquette? Greeting etiquette? Etiquette
surrounding business?
5. What are the norms of male/female relations?
6. What is the cultural perspective on privacy? Personal space?
7. What is the accepted form of dress? What is appropriate for casual/formal
situations?
8. Are their any religious customs that you should be aware of?
9. When are the national, local holidays? What are the significance of these
days?
10. Are there special rituals, customs to observe when entering government
buildings? Places of worship?
6. TED talk ….food for thought
http://www.ted.com/talks/lang/en
hans_rosling_reveals_new_insights_on_poverty.html
Hans Rosling’s Key Messages ?
Hans Rosling’s Key Messages
• There are many stages of development
• Asia and Africa,etc. are progressing from a health
/economic perspective – far faster pace than we
perceive
• Health progress surpasses economic progress
Means of Development?
Economic growth
Governance
Education
Human resources
Environment
Goals of development?
Health
Environment
Human rights
Culture
7. Motivations
1. Motivations I’d rather suppress
2. Motivations I can tolerate
3. Motivations to which I aspire
Philpott. American Medical Association Journal of Ethics 2010. 12 (3)
8. Ethical Challenges
Are global health experiences really
different than others?
Are global health experiences really
different than others?
• Greater disparity between health care professional and patient
(power imbalance)
• Cultural differences between professional and patient
• Health conditions may be tied to underlying societal problems
(structural violence)
- Lack of responsive governments, effective public health systems and
adequate “social safety nets”
- Lack of infrastructure: clean water, consistent power, roads and public
transportation, adequate facilities
- Lack of health care resources in certain settings, including health
professionals from the patient’s community
- Environmental stresses, resource depletion
Proposed ethical principles for students in
GH
Humility
– Recognizing own limits, eg., clinical skills and
experience
– Challenging “medical tourism”
– Questioning: one’s place in the world, especially where
some lives are valued more than others
– Especially important in research goals/activities
– Role as a learner
Pinto AD, Upshur R. Developing World Bioethics 2009; 9 (1): 1-10.
Introspection
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Motives: clinical & research
Is the expense justified?
Coming from privilege: class, ethnicity, gender,
education
Anti-discriminatory analysis
What will impact be of research?
Addressing the “know-do gap”
Solidarity
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Goals aligned with patients & community
Conflicting visions of health needs
Bridging power imbalances
Challenges: economic, political, social
Global commons
“Moral imagination”: ability to imagine ourselves in
the shoes of others, to change our outlook and actions
McCoy D, Sanders D, Baum F, Narayan T, Legge D. Lancet 2004;364:1630-1
Benatar S. PLoS Medicine 2005;2:e400
Social justice
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Diminishing gross inequality & address structural
violence
Explicit commitment
“Historically deep & geographically broad” analysis
Examine power relationships (politics) and understand
one’s own role
Community perspective: global
Farmer P. Berkeley: University of California Press, 2003.
Childress J et al. Journal of Law, Medicine & Ethics 2002;30:170-8
Reflective Writing Exercise
Take 10minutes to write a letter to yourself, describing your motivations for
the elective your are departing on. Please take the time to reflect on your
aspirations and hopes for this elective, as well as your fears/concerns.
Copyright: David Cornwell, First Light Pictures Inc.
Ethics: Real Case Studies
 Triage and decision making about limited resources:
 Limited amphotericin B available to treat suspected cryptococcal meningitis
 Patient autonomy vs. collective decision-making:
 Woman in labour requires an urgent C-section. The permission of her husband
is required, but he cannot be found.
 Aggressiveness of care:
 Young woman identified in a rural village with advanced HIV/TB. Take her to the
hospital or not?
9. Return and Debrief
Return & Debrief
• Despite adequate preparation, there are often experiences
while on electives abroad that can bring up both strong
responses and ethical dilemmas.
• Reflection can bring meaningful insight.
• Its normal to experience a variety of emotions on returning
from elective experiences abroad: relief, guilt, anger - can
make the re-adjustment to ‘normal life’ at home more
challenging.
Post-Return De-brief
• Re-visit your original expectations and motivations
after your elective experience.
• A post-return de-brief session will be offered to all
elective students in the spring of 2013 – please join
us and share your experiences and reflections.
Summary
• Global health is fundamentally about addressing
health inequity through meeting the needs of
vulnerable populations, both at home and abroad
• Preparation before an elective is essential
• Consider your health and safety, ethical and crosscultural challenges, as well as practical ways to
make the most of your experience.
Questions and Discussion?