Best Practices for Short Term Medical Teams

Similar articles can be found on my blog Medical Missions 101 Understanding Global Access to Health Care as a Social Justice Issue I believe global lack of access to health care for the poor is one of the most pressing social injustices of our world today.  In reviewing the global health inequities it is very hard not to see this as a social justice issue. One study that appeared in the Lancet tells us that at least 4·8 billion people in the world do not have access to surgery. This equates to greater than 95% of the population in south Asia and central, eastern, and sub-Saharan Africa not having access to surgical care. Whereas less than 5% of the population in Australia, high-income North America, and western Europe lack access (Alkire, et al., 2015). A Global Health Care Workforce in Crisis The global health care workforce is in crisis, so the need for global health engagement has never been greater. The World Health Organization (WHO) tells us there is a need for another 7.2 million health workers in the developing world and this shortage is expected to grow to 12.9 million by 2035 (World Health Organization, 2013). The WHO also warns that if this crisis is not addressed now to slow or stop the growth of this shortage, it will have serious implications for the health of billions of people across all regions of the developing world. Global Health Inequities The World Health Organization (WHO) also tells is that 5.9 million children under age five died in 2016, about 16,000 every day. The risk of a child dying before the age of five is still highest in the Sub-Saharan Africa at 81 per 1000 live births, which is an incredible seven times higher than in developed nations. Compare that with the WHO European Region where that number is 11 per 1000 live births. The under-five mortality in low-income countries remains unacceptably high averaging 76 deaths per 1000 live births. This is about 11 times the average in developed countries, which is 7 deaths per 1000 live births (World Health Organization, 2017) (United Nations inter-agency group for child mortality estimates, 2015). Maternal mortality is also a enormous problem. 830 young women loose their lives each day ( about 330,000 annually) due to complications and 99% of those deaths are in developing countries; a direct result of lack of functional functional healthcare systems with surgical capabilities (World Health Organization, 2018).  A True Social Justice Issue One way to spot a true social justice issue is look where the Christians are working on behalf of the poor. Out of all the players in global health care, Christians have been by far the most actively  engaged in this problem. However, I fear this high level of engagement is now changing. There have been hundreds if not thousands of mission hospitals founded by many Christian denominations, these mission hospitals are often the only access to lifesaving healthcare for vulnerable populations. Motivated by faith and passion to share the compassion, love and mercy of Christ nearly every Christian denomination created hospitals and health programs to care for the poor globally. The Role of the Church in Global Health Care Christian Mission hospitals and health programs account for about 50% of all healthcare delivered in Sub-Saharan Africa (Olivier, et al., 2015). That figure is probably closer to 70% of the truly functional healthcare services delivered.  Sadly however, many of these Christian facilities are closing, those that remain are fighting for survival. This is not isolated to African countries, a recent report  tells us there have been approximately 200 Christian hospital closings in India alone in the last two decades. These facilities are often in remote rural locations making it difficult to attract and keep national health professionals and the only access to lifesaving healthcare for vulnerable populations. Christian missionary physicians and nurses started these facilities and have staffed them since their inception, however there are no longer enough medical missionaries to staff them. Our best estimates are that there are only about 1300 missionary healthcare providers  still serving full-time around the world. This is not nearly enough to cover even a small percentage of the need. This has left many poor communities without any access to functional healthcare, or the Christian witness these facilities once provided. As a global Church we cannot disengage from health care,  it is part of our identity as a faith community. It is no accident that out of the nearly 4,000 verses in the 4 gospels, 727 of them have to do with healing. The Churches role in health care for the poor globally is, and should continue to be, our tangible expression of Christ to the nations that we cannot abandon. Alkire, B., Raykar, N., Shrime , M., Weiser, T., Rose , J., Nutt, C., . . . Farmer, P. (2015, June). Global access to surgical care: a modelling study. The Lancet, 3, 316-323. United Nations inter-agency group for child mortality estimates. (2015, September). Inter-agency Group for Child Mortality Estimates. New York: UNICEF. Retrieved from https://www.unicef.org/publications/files/Child_Mortality_Report_2015_Web_9_Sept_15.pdf  World Health Organization. (2013, November 11). WHO Media Center . Retrieved from World Health Organization : http://www.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/ World Health Organization. (2018, February). Fact Sheet on Maternal Mortality. Retrieved from World Health Organization Newsroom Fact Sheets: http://www.who.int/news-room/fact-sheets/detail/maternal-mortality  

6 Lifesaving Interventions for Children in Low-income Countries See this article with clinical pictures at http://www.healthservicecorps.org/6-interventions/ Saving the lives of children is one of the greatest joys of medical mission work. What if you could save the lives of not a few but of many children? This blog shares six very basic interventions that can help you achieve that aim. According to the World Health Organization (WHO) estimates on child mortality, 5.9 million children under age five died in 2015, about 16,000 every day. The risk of a child dying before the age of five is still highest in the WHO African Region at 81 per 1000 live births, which is a dramatic seven times higher than in developed countries. For comparison, in the WHO European Region that number is about 11 per 1000 live births. The under-five mortality in low-income countries remains unacceptably high averaging 76 deaths per 1000 live births. This is about 11 times the average in developed countries, which is 7 deaths per 1000 live births. We believe short-term and long-term medical missions have an important role to play in reducing these inequities across the world. However, the extent of the effectiveness of our medical missions on child mortality will be directly correlated to the level at which we learn and engage with international standards for the care of children in low-income countries. These six interventions, if used and promoted widely, can at help engage medical missions in this important fight. The doses listed in this blog post represent current recommendations published by the WHO although this blog post is meant only as an overview of information. It is not a comprehensive study of dosing or treatment modalities. We recommend downloading the reference from which these dosing recommendations were obtained. To download the IMCI chart booklet for dosing and process information IMCI Chart Booklet and Dosing Reference Guide. The complete computer-based IMCI training programs can be downloaded from the Christian Health Service Corps website at CHSC Clinical Resources. Please use and share these six child lifesaving interventions for children living in resource-poor communities: 1. Promotion of exclusive breast feeding for infants younger than six months This is probably the simplest of all interventions and yet it is the most effective. Communities should be educated on the importance of breast feeding. Improving exclusive breastfeeding practices of infants under six months of age has the greatest potential impact on child survival, higher than all other preventive interventions. According to Vesel et al (2009) improved breastfeeding practices could prevent over 800,000 deaths in children under age five every year. Simply counselling all mothers of young infants about the need for exclusive breast feeding can save the lives of many infants. 2. Immunizations About 10% of the diseases affecting children under five years of age are preventable with vaccines. A review of 12 studies found that measles immunization was associated with reductions in total mortality that ranged from 30–86%. Additionally, providing vitamin A supplements as part of measles case management can reduce the case fatality rate by more than 50%. Collaborating with local health departments and ministries of health to deliver vaccinations in rural unreached areas remains an underutilized strategy by medical missions and global health programs. There are many barriers to vaccination delivery in rural villages for local governments. Limited personnel and maintaining cold chain are but a couple. This medical mission strategy could help close this gap for some regional health authorities and improve vaccination coverage. Few medical mission or service learning programs engage in this type of collaborative efforts, but these projects can have lasting impact on child survival in rural areas. 3. Parasite prophylaxis Remember, many children in low income countries receive less than 50-75% of the daily-required caloric intake for growing children. Parasites further compromise the nutritional status of children. The WHO standard for parasite prophylaxis is to give all children one year or older mebendazole if they have not had a dose in the previous six months. • Give 500mg mebendazole as a single dose in clinic if 1) hookworm/whipworm is a problem in the area in which you will be working, 2) the child is one year of age or older, or 3) the child has not had a dose in the previous six months. 4. Vitamin A treatment In malnourished, micronutrient-deficient children, Vitamin A supplementation can reduce mortality by up to 23%. Vitamin A is important in interrupting the cycle of malnutrition that makes even mildly malnourished children susceptible to death in the event of a viral or bacterial illness. The vicious cycle of malnutrition and the way in which it claims the lives of even mildly malnourished children is illustrated below. It is an important topic to consider before seeing pediatric patients in developing countries. Malnutrition underlies more than 50% of the deaths of children under age five in the developing world. Diarrhea, acute respiratory illness, malaria, and vaccine-preventable diseases are the primary killers of children under five, but malnutrition is often the underlying factor that precipitates the child’s death. Children in developing countries who exhibit any signs of malnutrition should receive Vitamin A in much higher doses than practitioners trained in developed countries are familiar with prescribing. It should be noted that active collaboration with local health authorities and record-keeping is a fundamental requirement. • Give the first dose of Vitamin A any time after six months of age to ALL CHILDREN; thereafter, give Vitamin A every six months to ALL CHILDREN. • Give an extra dose of Vitamin A (the same dose as for supplementation) as part of treatment if the child has measles or PERSISTENT DIARRHEA. • If the child has had a dose of Vitamin A within the past month, DO NOT GIVE VITAMIN A. • Always record the dose of Vitamin A given on the child’s chart (i.e., AGE, VITAMIN A DOSE). • Dosage: Six months up to twelve months – 100,000 IU; one year and older – 200,000 IU 5. Zinc supplementation Zinc supplementation has been shown to reduce diarrhea incidence by 18% and pneumonia incidence by 41%. All children age two months up to five years presenting with diarrhea should receive the following: Instruct the mother on how much zinc to give (20-mg tab): • Two months up to six months – half a tablet daily for 14 days; six months or older – one tablet daily for 14 days. Demonstrate to the mother how to give zinc supplements; have her verbalize and (ideally) demonstrate how to mix and give the first dose. • Infants – dissolve tablet in a small amount of expressed breast milk, ORS, or clean water in a cup. • Older children – tablets can be chewed or dissolved in a small amount of clean water in a cup. 6. Iron supplementation for Childhood Anemia In developing countries, childhood anemia is a manifestation of micronutrient malnutrition and is often worsened by recurrent bouts of malaria. It is an extremely common symptom of mild to severe forms of malnutrition. According to the IMCI child health standards, all children who exhibit signs of anemia should receive the following: . TALC has hemoglobin color strips to use with finger-stick blood tests available at low cost for short-term global health initiatives. Palmar Pallor is the WHO standard for assessment of anemia in children in resource limited settings where there is blood hemoglobin measure available. Iron supplementation has also been shown to improve child development in children over age two and can have a significant affect on micronutrient-deficient children. Give iron daily for 14 days in the presence of childhood anemia. Give an oral antimalarial co-artemether in the presence of anemia in high malaria-risk areas as follows. Give the first dose of co-artemether in the clinic, and observe for one hour. If the child vomits within an hour, repeat the dose. The second dose is given at home after eight hours, then twice daily for a further two days as shown below; co-artemether should be taken with food. World Health Organization, 2017) Vesel, et al., 2009 Hill, Kirkwood, & Edmond, 2004 WHO/UNICEF, 2014 Hill, Kirkwood, & Edmond, 2004 WHO/UNICEF, 2014 Hill, Kirkwood, & Edmond, 2004 Hill, Kirkwood, & Edmond, 2004) WHO/UNICEF, 2014