I chose to apply to the global health pathway because I had a vision of pursuing such work in the future. Having spent 2.5 weeks in India, I am starting to refine that vision, as a result of both our observational experiences and didactic teaching sessions led by “Dr. James.” The latest small group discussion was very applicable to this topic as it centered on an article concerning the negative aspects of short-term medical missions. This was also a topic discussed in Mandy’s (fellow pathway member) master’s thesis. Perhaps the crux of the problem was that such missions were based off of the desires of the groups organizing them – and not of the population to be served. Closely related to this was the potential for harm which stemmed in part from a lack of awareness of cultural differences; for instance, not being aware that your patients cannot read the instructions on a bottle for a potentially toxic medicine. Also troubling was the fact that short-term missions created a “feel good” effect on the part of those doing the work without any real effort to evaluate the impact on locals of what had been done.
The examples provided were not exact parallels to our observational trip, my experience on month-long elective in Botswana, or how I envision my activities in the future. However, they were useful in pondering how to perform global health work in the most appropriate manner possible. Several factors seem to be important. First, ethical considerations dictate that the service provided is something deemed necessary by the population being served. We had read about polio eradication efforts in northern India being stymied by the fact that locals needed a whole host of more pressing medical services, and were frustrated by an apparent lack of interest in addressing these concerns vs. the little-realized threat of polio. For general medicine or subspecialty work this warning may not seem to apply. However, it does serve to highlight the fact that patients will not follow medical instructions unless they understand the impact of not doing so. In other words, the need to realize what is important to the patient – always significant in any medical interaction – is more difficult to ascertain when there are cultural barriers. In India, where the paternalistic culture of medicine is still strong, patients by and large only speak when spoken to. Beyond this, they rarely raise questions (or “doubts” as they are called), and often may not be given the time to do so. Is it any wonder that home drug courses, especially long ones, are not completed?
That brings us to another consideration: language. In Botswana I relied upon nurses and medical students for translation for the great majority of my patients, and on occasion had to do without a patient history. Botswana and India are both former British colonies where most educated people speak English well. Although English has become the global common tongue, the ability to provide good care and not inadvertently do harm must be increased for non-fluent providers in non-English speaking countries (e.g., Latin America). Ideally, global healthcare should be provided by physicians who can speak the language of their patients on at least an intermediate level. Learning a language takes time and exposure – things which may not be readily available to physicians.
Working in any country, or region within a country, requires knowing the political lay of the land. I mean “political” in both a straightforward and more general sense. Knowing who has the power to sign official documents, influence staff to make necessary systems changes, or exert pressure on higher-ups for necessary resources is a whole aspect of delivering care for which no course is offered. Moreover, what is the political situation of your area of operation? Where does funding come from and how stable is it? Most importantly, what are the resources of the hospital or clinic you are joining and are they always readily available? Are they reliable? At Snehakiran we had heard of normal liver function tests for a patient with obvious jaundice. An alternate laboratory showed high levels. In Botswana swabs of skin flora of staff members yielded uniformly negative cultures, confirming that culture data from the hospital microbiology department could not be trusted.
The considerations above imply that, practically speaking, much global health work relies on effective partnerships with local organizations. Close relationships between institutions are formed and naturally grow over time (“three cups of tea” being just the tip of the iceberg). Ideally, a global health endeavor grows from local institutions and people, who must be invested if there is to be a lasting impact. Finally, global health work should be at a center which can provide lasting care. A hospital ward that offers no follow-up outpatient care for its patients is limited in what it can achieve for them, particularly for those with chronic conditions.
In sum, global health is based off of local partnerships with people who speak the language, know the political landscape, can best determine the needs of their region, and provide long-term care for patients. Medical knowledge aside, I have realized that performing effective global health work implies cultural awareness on many levels, and cultivating the relationships with individuals that make such awareness possible… but that may have been what interested me in global health in the first place.