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Global Health in US Medical Education: A Focus on Israel and Palestine David McRay, MD Director of Maternal-Child Health John Peter Smith Hospital Family.

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Presentation on theme: "Global Health in US Medical Education: A Focus on Israel and Palestine David McRay, MD Director of Maternal-Child Health John Peter Smith Hospital Family."— Presentation transcript:

1 Global Health in US Medical Education: A Focus on Israel and Palestine David McRay, MD Director of Maternal-Child Health John Peter Smith Hospital Family Medicine Residency Fort Worth, TX Texas Tech University Health Sciences Center September 28, 2012

2 What is global health? Am J Public Health 2006; 96:67-72 Global Health Attempt to understand and reduce health disparities at home and abroad Working collaboratively with other communities and countries to improve community health locally and globally Learning about health issues that transcend geographic borders and commonly present a greater burden to disadvantaged populations

3 What is global health? How is it different from international health? Houpt, et al. Acad Med 2007; 82(3): 222-5 Global health stresses the global commonality of health issues that transcend national borders, class, race, ethnicity, income, or culture. Disease patterns vary geographically but the factors that foster disease onset are often the same. Rise of NCDs highlights our sameness

4 What is global health? How is it different from international health? Director General of the World Health Organization: In the past, desperate conditions on another continent might cynically be written out of ones memory. The process of globalization has made such an option impossible. The separation between domestic and international health problems is no longer useful. Speech in New York, NY – April 19, 2001 Global emphasizes sameness International emphasizes differences

5 Why is global health education important and popular? Fam Med 2011; 43(1):21-28 Expansion of global travel and trade Risk of rapid transmission and spread of infectious diseases (e.g. HIV, Avian flu, H1N1) Common and increasing burden of NCDs Increasing immigration

6 Why is global health education important and popular? Acad Med 2009; 84:320-325 Increasing travel and migration has led to a globalization of disease Physicians must understand: Global burden and epidemiology of disease Disparities and inequities in global health systems Importance of cross-cultural sensitivities

7 Why is global health education important and popular? United States 40 million residents who were born abroad 13% of US population 1,161,000 people immigrate to the US annually 25% of US population growth 60 million US residents travel abroad annually Increasing number to developing or majority-world countries

8 Why is global health education increasing in the US? ACGME annual report US medical students are increasingly interested in volunteering and global health electives 2007 – 26.3% 2011 – 30.5% Seeking experiences in cultural awareness and cultural competence 2007 – 47.2% 2011 – 69.1%

9 Why is global health education increasing in the US? ACGME annual report US medical students with experiences in a free clinic for an underserved population 2011 – 70.8% This question was not asked in prior years US medical students perception of their education in: Health care systems – 2011 – 37.1% inadequate Global health issues – 2011 – 38.1% inadequate Down from 43.3% in 2007

10 Why is global health education increasing in the US? Since 2000, 23.1% of all US medical students have participated in international training annually Fam Med 2011; 43(1):21-28 More than 25% of US medical school graduates enter residency training with some international health experience Acad Med 2009; 84: 320-325 – Drain, et al Nearly all medical schools have incorporated some form of global health teaching into their curricula

11 Global Health Education in Family Medicine 300 of 450 FM residency programs offer exposure to global health Some have GH electives without didactics or faculty support Some have formal programs with international travel with faculty mentors (like JPS) 90 programs are listed in the AAFP directory www.aafp.org/international/residencies AAFP Global Health Workshop

12 Global Health Education in Pediatrics Pediatrics 2011; 128(4): e959-965 2010 publication of a 2007 survey of pediatric residency graduates 59% - global health training was available 21% - participated 22% - global health training was essential or very important in selecting a residency 30% - definitely/very likely to work/volunteer in a developing country after residency

13 What is global health education/training? Acad Med 2007; 82(3): 222-5 Three domains of competency in global health education: recommendations for all medical students – Houpt, et al Global burden of disease Travelers medicine Immigrant health But, no standardized curriculum exists for medical schools or residencies (Drain, et al)

14 Strategies to meet global health interest of medical students Drain, et al. Academic Medicine 2007; 82 (3): 226-30 Integrate global health topics into core medical curricula Offer courses on global public health and tropical medicine Offer various elective courses, e.g. medical anthropology, international development and health, or health and human rights Establish a global health pathway or track to recognize international experiences and training Offer combined degree programs (e.g. MD/MPH) in global health

15 Strategies to meet global health interest of medical students Drain, et al. Academic Medicine 2007; 82 (3): 226-30 Provide academic, logistic, and financial support for international rotations Establish a global health administrator or office within the medical school Form international partnerships with developing- country institutions Create more scholarships and financial support for international exchanges Make an international clinical rotation a routine part of medical education

16 What do graduates DO with global health training? Long-term (career) work in majority world country Short-term volunteer missionary medicine Consultants Educators WHO, UN, etc. Travel medicine Refugee care Underserved populations in US Better citizens – locally and globally

17 John Peter Smith Hospital Family Medicine Residency Strong interest in international travel and health among residents Provision made for international electives Faculty participation in international trips Development of rural/international track Change of focus/name to global health Development of global health fellowship (P4 program)

18 JPS FMR Global Health Sites Haiti Palestine Thailand Russia Mexico Ghana India Uganda

19 John Peter Smith Hospital Family Medicine Residency Current options: Thailand – 2-4 weeks Haiti – 7-10 days Palestine – 4 weeks Russia – 1-2 weeks Mexico (El Paso, TX) – 1 week Ghana – 4 weeks Uganda – 3-4 weeks Others – Ethiopia, Papa New Guinea [India] Institute for International Medicine (http://www.inmed.us/)

20 JPS Global Health Elective to Palestine Origins 1969 or 1972 2000 2004 2009 Goals Improve understanding of health systems (systems- based care – ACGME) Introduction to the humanitarian and health care consequences of military occupation and oppression

21 JPS Global Health Elective to Palestine Structure One month 6-7 family medicine residents and/or medical students Visits to hospitals and clinics throughout the West Bank (and briefly in Israel – Beer Sheva and Jerusalem) Lectures and conversations Expectations Introductory historical/political reading Lancet series on health care in Palestine Participation in lectures and small group conversations Write two essays Make a presentation to peers after return

22 oPT (Palestine) West Bank and Gaza Population – 3.9 million (1.4 million in Gaza – 360 sq km, twice the size of Washington D.C.) Poverty – 67% in WB, 88% in Gaza Less than 2.7 USD/day for a family of four 50% rely on donor food for some of daily food need Unemployment – 27% in WB, 40% in Gaza Health (UNICEF, 2007) Infant mortality – 25.3 Under 5 mortality – 28.2 Stunting – 10% Maternal mortality – 11

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25 Qalqilya Nablus Ramallah Bethlehem Hebron

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28 Juzoor Foundation for Health and Social Development Juzoor – Roots in Arabic Palestinian NGO -founded in 1996 Improve the health and well-being of Palestinian families Promote health as a basic human right Focus Impact health and social policies Provide continuing professional education/development Empower communities

29 Juzoor Foundation for Health and Social Development Opportunities through Juzoor Qalqilya Hospital - UNRWA Princess Aliya Hospital in Hebron – MOH Al-Makassed Hospital in Jerusalem – NGO – Islamic Charitable Society Augusta Victoria Hospital in Jerusalem – NGO – Lutheran World Federation An Najah University Medical School - Nablus Refugee Camps – outpatient clinics Other formal educational experiences Meetings with MOH official ALSO course in Jericho and Bethlehem Ethics education

30 Qalqilya – West Bank

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32 Qalqilya Hospital

33 Qalqilya Hospital - OR

34 Qalqilya Hospital - ER

35 Qalqilya – Separation Wall

36 Juzoor Foundation for Health and Social Development Opportunities through Juzoor Qalqilya Hospital - UNRWA Princess Aliya Hospital in Hebron – MOH Al-Makassed Hospital in Jerusalem – NGO – Islamic Charitable Society Augusta Victoria Hospital in Jerusalem – NGO – Lutheran World Federation An Najah University Medical School - Nablus Refugee Camps – outpatient clinics Other formal educational experiences Meetings with MOH official ALSO course in Jericho and Bethlehem Ethics education

37 Princess Aliya Hospital - Hebron

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40 Juzoor Foundation for Health and Social Development Opportunities through Juzoor Qalqilya Hospital - UNRWA Princess Aliya Hospital in Hebron – MOH Al-Makassed Hospital in Jerusalem – NGO – Islamic Charitable Society Augusta Victoria Hospital in Jerusalem – NGO – Lutheran World Federation An Najah University Medical School - Nablus Refugee Camps – outpatient clinics Other formal educational experiences Meetings with MOH official ALSO course in Jericho and Bethlehem Ethics education

41 Al Makassed Hospital - Jerusalem

42 Al Makassed Hospital - Ethics

43 Juzoor Foundation for Health and Social Development Opportunities through Juzoor Qalqilya Hospital - UNRWA Princess Aliya Hospital in Hebron – MOH Al-Makassed Hospital in Jerusalem – NGO – Islamic Charitable Society Augusta Victoria Hospital in Jerusalem – NGO – Lutheran World Federation An Najah University Medical School - Nablus Refugee Camps – outpatient clinics Other formal educational experiences Meetings with MOH official ALSO course in Jericho and Bethlehem Ethics education

44 Augusta Victoria Hospital - Jerusalem

45 Augusta Victoria Hospital - Ethics

46 Juzoor Foundation for Health and Social Development Opportunities through Juzoor Qalqilya Hospital - UNRWA Princess Aliya Hospital in Hebron – MOH Al-Makassed Hospital in Jerusalem – NGO – Islamic Charitable Society Augusta Victoria Hospital in Jerusalem – NGO – Lutheran World Federation An Najah University Medical School - Nablus Refugee Camps – outpatient clinics Other formal educational experiences Meetings with MOH official ALSO course in Jericho and Bethlehem Ethics education

47 An Najah University Faculty of Medicine

48 Juzoor Foundation for Health and Social Development Opportunities through Juzoor Qalqilya Hospital - UNRWA Princess Aliya Hospital in Hebron – MOH Al-Makassed Hospital in Jerusalem – NGO – Islamic Charitable Society Augusta Victoria Hospital in Jerusalem – NGO – Lutheran World Federation An Najah University Medical School - Nablus Refugee Camps – outpatient clinics Other formal educational experiences Meetings with MOH official ALSO course in Jericho and Bethlehem Ethics education

49 UNRWA Health Centers

50 Juzoor Foundation for Health and Social Development Opportunities through Juzoor Qalqilya Hospital - UNRWA Princess Aliya Hospital in Hebron – MOH Al-Makassed Hospital in Jerusalem – NGO – Islamic Charitable Society Augusta Victoria Hospital in Jerusalem – NGO – Lutheran World Federation An Najah University Medical School - Nablus Refugee Camps – outpatient clinics Other formal educational experiences Meetings with MOH official ALSO course in Jericho and Bethlehem Ethics education

51 ALSO - Jericho

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53 Ethics Education Workshop

54 oPT (Palestine) Palestinian Medical Relief Society Grassroots, community-based, non-profit 1979 – group of Palestinian doctors and health professionals – to supplement the decayed and inadequate health infrastructure Many national health programs focusing on the needs of the most vulnerable (women, children, disabled, and poor in rural villages, refugee camps, and urban centers) 26 primary care clinics 8 mobile clinics Emergency centers Laboratories, pharmacies, school-based clinics School of Community Health

55 oPT (Palestine) Holy Family Hospital in Bethlehem – NGO – Sovereign Order of Malta Leading obstetric and neonatal facility in Palestine >3000 deliveries per year Almost 50,000 deliveries since reopening in 1989 18 bed NICU Operated by standards of the Royal College of Obstetrics and Gynecology Outcomes comparable to institutions in US and UK

56 ACGME Competencies Patient Care Outpatient clinics, inpatient wards, ED, hospice, mobile clinics Common medical problems, as well as illnesses related to the patients circumstances – trauma, infection, malnutrition, etc. Medical Knowledge Across the life cycles End-of-life care, mobile (Bedouin and Palestinian), trauma Community Health Community health assessment, use of resources, development of specific programs to meet needs, health education

57 ACGME Competencies Practice-based Learning and Improvement Interpersonal and Communication Skills Across cultural/ethnic/linguistic/socioeconomic barriers with patients, families, and other healthcare providers Professionalism Challenges – people groups, political situations, historical contexts, cultural interactions Consider issues of fairness and justice Test ability to respond with sensitivity and integrity Didactic exercises to strengthen/test ability to identify and discuss core ethical issues

58 ACGME Competencies Systems-based Practice Introduced to complex, new systems of care Israel National healthcare system Regional primary care-based system Central leadership role of family physicians Considerations of cost and advocacy Palestine Four components of the system Ministry of Health of the PA NGOs UNRWA Private Evaluate the effectiveness of primary care and role of family physicians

59 Plans and Questions – Sept 2008 First trip in March, 2009 Start small – one or two residents, one or two medical students Housing – limited options in Beer Sheva Funding Travel costs Eventually need funds to reimburse BGU Department of Family Medicine for time spent teaching How to recruit medical students?

60 March 2009 – 2 JPS residents and 1 student March 2010 – 6 JPS residents March 2011 - 1 JPS resident and 5 students March 2012 – 3 JPS residents, 2 students, 1 PT Increasing opportunities for clinical involvement Ethics curriculum Advanced Life Support in Obstetrics Develop family medicine curriculum at Al Quds University Medical School in Jerusalem Family Medicine residency at An-Najah National University in Nablus Update

61 JPSH Family Medicine Global Health Elective in Israel and Palestine

62 Expansion - 2012

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64 Resources for Global Health

65 American Academy of Family Physicians

66 AAFP – Center for International Health Initiatives

67 AAFP – Global Health Workshop

68 Global Health Education Consortium

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71 Thank you Questions?


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