2. The Impact of Short-Term Medical Mission on our Learners: Examples from the Field Deborah K. Witt, MD Thomas Jefferson Department of Family & Community Medicine Kelechi A. Uduhiri, MD, MPH, MS Franklin Square Hospital Center Department of Family Medicine Annette B. Gadegbeku, MD Drexel University College of Medicine Department of Family, Community, & Preventative Medicine

3. OBJECTIVES DEFINE SHORT-TERM MEDICAL MISSIONS OUTLINE BENEFITS OF SERVICE LEARNING OPPORTUNITIES HIGHLIGHT FULFILLMENT OF ACGME COMPETENCIES DEMONSTRATE MEETING GLOBAL HEALTH PRIMARY CARE NEEDS

4. Short-Term Medical Mission Multidisciplinary team travel abroad Free mobile medical care to serve patients in areas lacking access to regular health care Short term - few weeks to one month Creative, non-traditional educational tool for our nursing, medical school, and residency curriculums

5. ACGME Core competencies PROFESSIONALISM PATIENT CARE INTERPERSONAL AND COMMUNICATION SKILLS MEDICAL KNOWLEDGE SYSTEMS-BASED PRACTICE PRACTICE-BASED LEARNING AND IMPROVEMENT

6. Current Literature Very few research studies on efficacy of short- term missions Most articles published on short-term missions are: – Reviews – Suggestions for implementation – Based on personal beliefs Mixed views

7. Current Literature Cont. Assess perceptions of short-term medical missions in Guatemala Interviewed patients, volunteers, local healthcare providers, and members of the community Recipient communities have varied opinions (positive and negative) Maki, et al., 2008 Green et. al., 2009

8. Short-Term Missions Challenges Prior criticisms: – Language/cultural barriers – Implementation – Poverty as root cause – Lack of follow-up care – Expectancy of free care – Interference with established health system – Lack of coordination – Quality of care

9. Overview of the ELECTIVE Feb 2008 offered intense 1- week program 2 nd and 3 rd year Family Medicine Residents and 4 th year medical students (4wks avail) Exploring Global Health service learning opportunities - Jamaica, Kenya, and Haiti Non-traditional setting – Collaboration with non profit Faith based organization Glory Unlimited Ministries 501 c 3

10. ELECTIVE CURRICULUM HOME VISITS EDUCATIONAL SEMINARS GIVEAWAYS FOOD, CLOTHES, ETC NURSING HOME VISITS HOMELESS CARE/STREET CHURCH HOSPITAL ROUNDS/ACCIDENT & ER WARD CULTURAL EXCHANGE IN COMMUNITY

13. Residents Comments “actually providing health care to a needy population and they are doing so in a long- term commitment” “it’s absolutely wonderful to see the continuity in patients charts” “it adds so much to our residency program” “I couldn’t believe the breathtaking views from our ‘mountaintop clinic’” “I had a life-changing experience”

14. Jamaica Population: 2.8 Million(2010) Life Expectancy - 69 yrs old (males) 74 yrs old (females) 16.5% lives below poverty Healthcare System: $383 annually per person 85 physicians/100,000 https://www.cia.gov/library/publications/the-world-factbook/geos/jm.html

16. Serving in Jamaica Training Ground Initial Visit - 2001 Community Needs Assessment Focus Groups Ministry of Health Relationship Licensure Volunteerism

18. Cases Family with Rickets Sexual Abuse 3 year old Rape/Incest Domestic Violence Severe Depression Mumps Home Remedies/Alternative Medicines Multiple skin diseases

20. Haiti Population: 10 million (2009) 80% lives below poverty Average life expectancy 54 yrs Nearly 2/3 of population survive on less than $2/day Healthcare system: $83 annually per person At least 50% of population no access to healthcare 25 physicians & 11 nurses per 100,000

21. Earthquake - January 12, 2010

22. Medical Concerns - Haiti Major causes of morbidity and mortality: – GI diseases (especially diarrheal) – Respiratory infections – Malaria – Malnutrition – CV disease – HIV/AIDS – TB – Stroke – Diabetes – Infant Mortality (home births)

23. Serving in Haiti Initial Visit 2/10 - Communities Bourdon, Croix-des-Bouquets, Meillur 4 Faculty, 2 med students, 2 FM residents, 2 NP students, 2 nurses (Total team 26) 724 patients seen by providers (includes - Santa Domingo, DR) 2nd Visit 9/10 - Church Communities 2 Faculty, 1 RN (Total team 13) - 300 patients

24. Age/Gender Breakdown - Haiti Age RangeMaleFemaleTotal% of Total <1 yr.1118294% 1-4 yrs.34427610.5% 5-11 yrs.877616322.5% 12-17 yrs.40438011% 18-39 yrs.6116122230.8% 40-64 yrs.357210714.9% 65+ yrs.824324.5% No age recorded210121.8% Total278446724100% Patients = 1.6 times as many women: men Population ratio men/women = 1.01 Age breakdown of patients vs. population = not statistically different

25. DiagnosisMaleFemaleTotal% of Total Diagnoses Infectious/Parasitic57451029.6% Endocrine/Nutrition616222% Blood Disorders518232.2% Mental Health2564898.4% Sense Organs/CNS2232545.1% CV2148696.5% Respiratory8210919118% Digestive2959888.3% Genitourinary/OB1010011010.4% Dermatologic1638545.1% Musculoskeletal3618545.1% Injury2730575.4% Other1516312.9% Healthy2630565.3% None given2635615.7% Total4036581061100%

26. Kenya Population: 41 million (2011) Average life expectancy 59 yrs. Nearly 50% of population live below poverty line Healthcare system: pay for service 14 physicians/100,000 (2002) https://www.cia.gov/library/publications/the-world- factbook/geos/ke.html

27. Medical Concerns - Kenya Major causes of morbidity and mortality – HIV/AIDS – Malaria – Respiratory infections – Malnutrition – Malignant hypertension and stroke – Diabetes

28. Serving in Kenya Nakuru 2 faculty, 1 NP student, 1 EMT 319 patients in total registered at the clinic 95 patients triaged and determined to not need medical treatment 224 patients saw providers Community Doctor for follow up

29. Age/Gender Breakdown- Kenya Age RangeMaleFemaleTotal% of Total <1 yr.111123.8% 1-4 yrs.26224815% 5-11 yrs.24305417% 12-17 yrs.910196% 18-39 yrs.219411536% 40-64 yrs.12455717.8% 65+ yrs.410144.4% No age given0000 Total97222319100% Patients = 2.3 times women: men Population ratio men/women = 1.01 Age breakdown of patients vs. population = not statistically different

30. DiagnosisMaleFemaleTotal% of Total Diagnoses Infectious/Parasitic15223710.7% Endocrine/Nutrition612185.2% Blood Disorders0000 Mental Health66123.5% Sense Organs/CNS516216.1% CV9273610.4% Respiratory18355315.3% Digestive13385114.7% Genitourinary/OB117185.2% Dermatologic916257.2% Musculoskeletal8354312.4% Injury57123.5% Other29113.2% Healthy5492.6% None given0000 Total102244346100%

31. Impact in Kenya – Numbers of patients seen- 224 in 2 days – Educational group sessions & seminars – Collaboration with Dr. Harun Cherop in Kenya – Temporary access to care for patients – Donations - meds/supplies – Referrals when necessary – Nurse triage in Kenya – Water project - 30,000 Liters in rural Mukineke

32. Haiti vs. Kenya Haiti- aftermath of earthquake; 724 patients – Reflective of acute care – Respiratory leading dx – GI, mental, genitourinary – 6% of patients referred out – Received treatment w/ HTN 1 or 2 = 45.7% – Received treatment w/ diabetes = 66.7% Kenya- no traumatic event; 224 patients – Reflective of chronic care – Respiratory leading dx – Musculoskeletal – 21% of patients referred out – Received treatment w/ HTN 1 or 2 = 68.2% – Received treatment w/ diabetes = 66.7% – Higher % of DM and HTN diagnosis

33. Blood Pressure N = 547, 64.9% adults Min = 74/42 Max = 240/110 JNC-7 Guidelines: Normal: SBP <120 and DBP <80 Pre-HTN: SPB 120-139 or DBP 80-89 HTN 1: SBP 140-159 or DBP 90-99 HTN 2: SBP ≥160 or DBP ≥100 HaitiKenya N = 170, 95.3% adults Min = 100/60 Max = 260/142

34. Diabetes Mellitus N= 11, 100% adults Min = 73 Max = 376 Normal: <100 Impaired: 100-126 Diabetic: ≥126 Haiti Kenya N= 23, 100% adults Min = 84 Max = 344

36. Summary: Lessons from the Field Awesome Experience for Residents & Students Meet ACGME Competencies & Milestones Form Collaborations with other NGOs Networking is crucial Engage in impactful services to resource poor areas Collaboration with 3 Academic centers works! Non Traditional Experience - Empowering!!

37. REFERENCES 1. Chapin E, Doocy S. International short-term medical service trips: Guidelines from the literature and perspectives from the field. World health & population [Internet]. 2010;12(2):43-53. 2. Central Intelligence Agency: The world factbook. [https://www.cia.gov/library/publications/the-world- factbook/rankorder/2004rank.html]. 3. DeCamp M. Ethical review of global short-term medical volunteerism. HEC Forum [Internet]. 2011:91-103. 4. Green T, Green H, Scandlyn J, Kestler A: Perceptions of Short-Term Medical Work: A Qualitative Study in Guatemala. Globalization and Health 2009;5(4): 4-17. 5. Jobe K. Disaster relief in post-earthquake Haiti: Unintended consequences of humanitarian volunteerism. Travel Medicine and Infectious Disease. 2011;9(1):1-5. 6. Maki J, Qualls M, White B, Kleefield S, Crone R. Health impact assessments and short-term medical missions: A methods study to evaluate quality of care. BMC Health Services Research. 2008;8(1): 121-129. 7. Ott BB, Olson RM. Ethical issues of medical missions: The clinicians' view. HEC Forum [Internet]. 2011:1-9. 8. Pan American Health Organization: Haiti Population Health Assessment Prior to Earthquake. [http://oneresponse.info/Disasters/Haiti/Health/Archives/Haiti%20pre- earthquake%20health%20situation%20assessment%20v2.pdf]. 9. World Health Organization Statistical Information System (WHOSIS): Human resources for health. [http://www.who.int/whosis/indicators/compendium/2008/3hwo/en/]. Text

38. 38 QUESTIONS Deborah.Witt@jefferson.edu Kelechi.Uduhiri@Medstar.net Agadegbe@drexelmed.edu www.gloryunlimitedministries.org 38