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 health2. Health and safety3. Cross-cultural learning4. Living and working in LMIC5. Starting a geo-journal6. TED talk7. Discussion around motivations8. Ethical challenges in global health9. Return and debrief

RationaleIncreasing 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 HealthVision: 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

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.

How family physicians can engage in global health

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: 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 & SafetySpecific travel notices and advisories

E.g. Malawi – measles advisorySafety and security

E.g. Ghana – avoid unnecessary travelGeneral safety and risk of crimeCivil unrestPay attention to areas of concern

Special precautions for foreignersSpecial precautions for womenLaws and customs

E.g. Malawi: "Homosexual activity is illegal"

Health & SafetyVaccine-preventable diseases:

Routine e.g. TDaP, IPV, MMR, meningitis, pneumococcalHep A & BTyphoidYellow fever (Rwanda)Rabies

Malaria prophylaxisNB: 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, sunscreenBug repellent, insect netBed netFood and water safety; Water purification tabletsAllergic reactions and asthma exacerbationBe aware of exposure to parasites: water (Lake Malawi),

wet clothes, etc

Health & Safety

Precautions

Do not travel at night if possibleDon’t use motorcycles - highest risk: MVCFollow the advice of your hostsDo 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

• 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: ResourcesTo bring:

Oxford Handbook of Tropical MedicineThe best resource is often locally developed treatment

guidelines! (e.g. Malawi)

Websites:www.mayo.edu/alumni/ATasteofTropicalMedicine.htmlwww.pitt.edu/~super1/globalhealtheducation.org/Modules/SitePages/Home.aspx

Reference: Lecture Notes: Tropical Medicine, Gill & BeechingWhere 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.aartichapati.com

www.oxforddictionaries.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 ShockMinimizing the effects of culture shock:

International awarenessCross cultural communication skills and sensitivityPrepare: bring stuff from home (photos, music); plan to keep in

touch with friends and family from homeBe open to the experienceKeep mentally and physically fitKeep a journalKeep 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 LMICWorkplace

• 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 LMICLiving 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.

ProfessionalismDrugs: 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_shock.html

5. Introducing a Geo-Journal

Key Questions

• 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?

http://www.ted.com/talks/lang/en hans_rosling_reveals_new_insights_on_poverty.html

6. TED talk ….food for thought

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 growthGovernanceEducationHuman resourcesEnvironment

Goals of development?

HealthEnvironmentHuman rightsCulture

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- 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 - 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;364:1630-1Benatar S. PLoS Medicine 2005;2:e400

Social justice- 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

Copyright: David Cornwell, First Light Pictures Inc.

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.

Ethics: Real Case StudiesTriage 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 cross-cultural challenges, as well as practical ways to make the most of your experience.

Questions and Discussion?