“The constitution” of primary health internationally, as a core component of the structure of health, care can be traced back to the Declaration of Alma-Ata (1978), even though its origins go much further back in time: 1941 in the Netherlands and 1948 in the United Kingdom. The Declaration states that governments have to be responsible for the health of their people. Primary health care is seen as an important vehicle to deliver health care to the population, and is defined as care that “addresses the main health problems in the community, providing promotive, preventative, curative and rehabilitative services accordingly.” The Declaration of Alma-Ata also states that by the year 2000 there should be “health for all.” ...continue reading
Lynn McIntyre MD MHSc FRCPC is Professor in the Department of Community Health Sciences, and Research Coordinator for the Public Health and Preventive Medicine program, at the University of Calgary, Alberta
I am sitting on a balcony in Mwanza, Tanzania looking out on Lake Victoria. This is the second public health and preventive medicine residency elective I have done here.
My institution, like many other North American universities, embraces global health educational opportunities and supports these experiences by covering some or all of residents’ travel expenses and facilitating contact with potential host institutions.
The Canadian Association of Interns and Residents supports global health electives as well and outlines institutional responsibilities related to resident participation. Their guidelines state that Postgraduate Medical Education Offices should offer residents predeparture training to address health, safety and “ethical challenges”; to designate a contact person; and to provide clear expectations. I have been thinking about these "ethical challenges" in addition to how sending institutions define their own responsibilities, not only towards their residents, but with regard to host institutions. ...continue reading
Giovanni Apráez ippolito is Professor of Public Health at School of Medicine, National University of Colombia and Adviser in Primary Care in Cauca Region, Colombia. Carlos Sarmiento Limas MD MPH is Head of Public Health at School of Medicine, National University of Colombia, and ex-medical officer in Ministry of Health in Bogota-Colombia
Colombia pioneered primary health care (PHC) in the Latin American Region from the 1950s until the beginning of the 90s. There was then a crisis in PHC due to reform of the national Health system (by law 100 in 1993), which adopted a system based on the insurance model. This led to two decades of debate without any structural changes, and Colombia became the focus for international discussions on PHC and Health Organization models. During the past 60 years there was also a war in Colombia that appears to have ended during the current national government (2014-2018).
The international consensus is that health systems based on PHC have better results, lower costs, guarantee the right of health of individuals and communities, promote comprehensive care, promote health, and contribute to achieving the Millennium Development Goals (MDGs), among many other benefits. Primary care is organised according to the individual circumstances in each country (WHO 2008) but, in our opinion, this structure must be predominantly public.
There is renewed interest in PHC in Columbia for several reasons ...continue reading
Kirsten Patrick is Deputy Editor at CMAJ
There's a quote from the film 'When Harry Met Sally', (Meg Ryan, Billy Crystal) that I always thought was rather profound. One of the supporting characters, a writer, says,
Restaurants are to people in the eighties what theatre was to people in the sixties.
That dates the movie, and me, but how much more true it is now, I think. In the past three or four decades food has come to define us socially and has evolved into entertainment more and more.
Earlier this week Dr John Fletcher and I published an editorial in CMAJ called 'A political prescription is needed to treat obesity', which garnered some criticism from two high profile Canadian bloggers. Dr Brian Goldman of CBC's "White Coat Black Art", only mildly critical, suggested that the idea of a donut tax was impractical given the ease of cross border shopping for Canadians. Dr Arya Sharma, who writes the daily blog "Dr Sharma's Obesity Notes", was far more derisive . Dr Sharma misinterprets our editorial and suggests that we are naively arguing that taxation and regulation of high-calorie and nutrient-poor food products is the ONLY viable approach to the obesity epidemic. Which, clearly, it is not. We are in no way in denial about the need for a multi-pronged, multi-generational approach in response to rising obesity. In fact, perhaps Dr Sharma did not read the whole editorial before pronouncing judgement as we clearly state: "Strategies that include individual interventions, school-based nutrition and activity interventions, incentives for active commuting and changes to thebuilt environment should continue; however, we also need robust ways to restrict portion sizes and reduce the sale of sugar-sweetened beverages and other high-calorie, nutrient-poor food products."
The problem of population level obesity is multifactorial and has been decades in evolution. Political solutions that involve laws and taxation will take years to show benefits - and obviously effective treatment and lifestyle-choice solutions will continue to be necessary. But that does not mean that we shouldn't back political solutions as part of a more comprehensive strategy for treating obesity and NCDs in the longer term. ...continue reading
“No, don’t touch the dead body!”
“Save yourself so you can save others!”
“Midwives, nurses, and doctors have died!”
“Entire families being wiped out!”
The above statements trigger memories of the experiences I had while in Liberia, each linked to one antagonist: EBOLA.
Hawa greeted her husband who just returned home from helping at a burial ceremony of a close friend who died suddenly of a terrible sickness. After being home for only a week, Hawa’s husband himself became sick with “hot skin” (fever), headache, “body pain” (myalgia), sore throat, cough, and fatigue. Hawa cared for him with traditional herbal remedies, but he continued to worsen. He suffered abdominal pain, severe nausea, vomiting, and “toilet fast-fast” (diarrhea). His eyes became gritty, tearful, and red. By day six of his illness, he was unable to get up, curled in a fetal position on the mat that was dirty with his vomit and excrements. It was impossible to keep him clean for long because of the continual vomiting and diarrhea. No one came to help her. Hopelessly, she watched her husband decline rapidly, bleeding from his gums and lips, becoming unconscious. He died soon after. ...continue reading
Dr Kirsten Patrick is Deputy Editor at CMAJ
Last week I was fortunate enough to be invited to a great workshop, organized by the CMA’s Public Health division, aimed at developing a unified policy and advocacy platform for humanitarian medicine. As the background reading material pointed out, many Canadian physicians are interested in participating in humanitarian medicine initiatives and work or volunteer abroad at different stages of their life and career. The problem is that many such activities are ad hoc, not optimally planned, fragmented, and undertaken without due consideration of their impact. The CMA hopes to co-ordinate efforts in Canada to explore and delineate best practices, and to optimize the way that global health activities are coordinated among NGOs, physicians, residents and medical students.
I’ve had some experience with developing guidelines for best practice during short term experiences in global health. In 2010 I was part of a group led by Jeremy Sugarman, professor of bioethics and medicine at Johns Hopkins, and John Crump, a professor at Duke’s Global Health Institute, that produced the first Open Access guidelines on Ethics and best practice guidelines for training experiences in global health. The first decade of the new century saw an explosion of global health programs that would send students and graduates for short term experiences, usually from a developed country to a less developed country (without much traffic in the other direction). To quote Sugarman, we now have a “stunning prevalence of initiatives covering a broad range of activities, institutions, and countries”, offered by “Governmental, Non-‐governmental, Religious, Humanitarian relief, Academic and Professional [organizations].”
In the early 1990s, as a medical student in Johannesburg, South Africa, I spent some clinical rotations in Baragwanath Hospital in Soweto. There I met many foreign medical students (mainly German and British) who came to get 'developing world experience' (mostly of performing surgery that they would not get to perform at home). If they were keen and hung around long enough sooner or later they’d get to do an appendectomy, or a circumcision, or excise a lipoma the size of a baseball. Ethically sound behavior? Mmmm. Not so much.
But it isn't just students. Trained physicians from wealthy countries also go to less well developed areas to offer their skills. Historically the pattern was for physicians to pack up their lives and go to live and work in an under-served area for many years. Yet in the last few decades the ease with which air travel and temporary accommodation can be arranged has changed this pattern. Now the opportunity exists for physicians to keep their ‘developed world lives’ relatively intact while taking a short trip to ‘do good’ somewhere else.
Do they do good? That's the million dollar question. While they may be motivated by good intentions there is no clear evidence that such activities are beneficial in an enduring way to the host countries. An oft-quoted paper points out that there IS benefit for physician who goes abroad for the brief stint, both for that physician personally and for his/her home country (because such people are more likely to work in under-served areas back home in their future careers). Trainers from leading humanitarian organizations acknowledge that one thing we DO know for sure is that there is always some harm that comes from even the most well-intentioned of humanitarian missions (see list of resources below).
Some of the ethical considerations and potential negative consequences of short term global health experiences were outlined in an influential 2008 JAMA article. The cynical term ‘voluntourism’ is perhaps a realistic descriptor of such activities, given their clear benefit for the traveler and much less clear benefit for the receiving community.
I think there is a particular difficulty for many who are fired up by the noble desire to ‘do good’ or ‘make a difference’ to stop and think about potential negative consequences of their well-intentioned behavior. Because how could giving up one’s time for the good of others be bad? Yet it is probably ‘placebo’ at best as some have argued “don’t go”. But realistically, without some Icelandic volcanic ash scenario in which all airplanes out of North America and Europe are grounded, physicians will continue to go abroad on global health ‘missions’. The only thing that we can do is increase awareness of ethical concerns, encourage physicians and students to think about scenarios ahead of time and endeavor to educate, educate, educate…. in the hope that the harm done by people going on global health experiences and humanitarian missions can be minimized.
The CMA meeting’s participants were top notch, representing all the main stakeholders leading the way in humanitarian activities and global health electives in Canada and some international players, perhaps with the notable exception of experts from countries who receive medical humanitarian missions and voluntourists. The CMA will produce an official report at the end of the process. In the mean time here are some educational and support tools that may be helpful to those who are thinking of going abroad to ‘do good’ in a medical way.
- The Johns Hopkins Berman Institute of Bioethics collaborated with the Stanford Center for Innovation in Global Health to produce an excellent case based online course on Ethical Challenges in Short-Term Global Health Training. [This course is based on the guidelines on Ethics and best practice guidelines for training experiences in global health I mentioned earlier; it is widely understood that case studies are the best tools to teach applied ethics…best for pre-departure training, but also useful as an in-field resource and to assist debrief after return.]
- HumEthNet, a website that developed out of empirical research on the ethical dilemmas faced by humanitarian healthcare professionals working in humanitarian crises, disasters or areas of extreme poverty.
- The Advanced Training Program on Humanitarian Ethics’ Humanitarian Principles
- The McGill Humanitarian Studies initiative, which offers the Canadian Disaster and Humanitarian Response Training Programs that range from an introductory course to an advanced program that includes simulation training.
- The 53rd week, a non-profit organization that aims to maximize the benefits derived from short-term volunteer initiatives using innovation, education, and research.