21: The Global Burden of Disease

December 13, 2021March 10, 2022 ~ Global EM Student Leadership Program ~ Leave a comment

Global Health and the Global Burden of Disease presented by Denise Manfrini

Global burden of disease is the quantity of disease (conditions, illnesses, injuries) and their impact on a population. The impact is measured in disability-adjusted life years (DALYs), which is the years of life lost from premature death and years of life lived in less than full health. There are other metrics used as well to compare countries, such as incidence, prevalence, mortality, and fertility rate.

In order to determine these metrics to measure global burden of disease and see where a country’s health system should focus, disease surveillance is required. This led to the creation of the Global Burden of Disease (GBD) Project in 1992. It aims to develop a consistent way to estimate disease burden in eight global regions (established market economies and formerly socialist economies) using the metrics described above, particularly the DALY. The project initially quantified 107 conditions and over 400 sequelae and has been expanding and updating its findings in the following years. This level of detail has allowed tracking of disease changes over the years and given insight into which interventions are effective. Initial results have shown high disease burden, premature mortality, and health disparities when comparing established market economies and impoverished countries; notably, developing countries suffered more from infectious and parasitic diseases, respiratory infections, and maternal and perinatal disorders. Developed countries suffered more from diseases due to poor lifestyle, such as cardiovascular disorders. Results from 2019 indicate shifts. Overall health is improving worldwide since those results in 1994 (GBD 2019 Diseases and Injuries Collaborators 2020). As seen in the chart, diseases affecting primarily children, such as respiratory infections, diarrheal infections, measles, neonatal disorders, tetanus, malaria, have decreased significantly. The prevalence of diseases affecting older adults, such as ischemic heart disease, diabetes, stroke, lung cancer, has increased and indicates that health care systems need to be prepared to manage an older patient population.

An alternative approach advocated for the right to health of every individual as envisioned in the Universal Declaration of Human Rights. The 1978 Alma Ata Declaration proposed that the fulfillment of these rights belongs to the international community through international collaboration. The past several decades has seen an increasing movement towards this idea and away from one based on economics. An example of this would be the recognition in the 1990s that citizens of developing nations with HIV are inherently as deserving of treatment as those from developed nations. By taking an approach rooted in human rights, the international community was able to lower the cost of HIV medication and provide treatment for patients in the developing world.

Once burden of disease can be quantified, how do we decide how to tackle it? Enter priority setting to determine how to best allocate resources. A few models have been proposed. In 1971, Abdel Omran posited four stages through which developing countries progress, called the epidemiological transition. The four stages are: age of pestilence and famine; age of receding pandemics; age of degenerative and manmade disease; and age of delayed chronic disease. Developed countries would be categorized in this final stage. However, the stages do not have clear divisions nor is the progression so clear-cut; a country can be in more than one stage simultaneously. For example, developed countries are currently suffering from the Covid pandemic and from chronic diseases. Thus, priority setting based only on the epidemiological transition would provide incomplete aid to countries encountering more than one stage. Another model is the idea of cost-effectiveness. For an intervention to be considered cost-effective, it must cost no more than 3x the per capita health costs. This is difficult to achieve in countries where the per capita health cost is extremely limited and not enough to cover a worthwhile intervention. After recognizing that poor health leads to limited economic development and to address the challenge of figuring out which interventions need investing, the Disease Control Priorities (DCP) Project was created. It aimed to enable countries to choose and prioritize interventions that maximally impact disease burden and that are supported by their health budgets. The latest DCP project promotes equity and advocates for universal health coverage. Both the DCP and GBD projects are ongoing.

Discussion Questions:

•To what extent should developed countries provide economic support to developing countries?

•Which diseases can we anticipate becoming a larger portion of the burden of disease and what can we do to prepare?

Tuberculosis: Global Policy and Impacts of COVID-19 presented by Andrew McAward

Prior to the current COVID-19 pandemic, tuberculosis was the leading cause of death from a single infectious disease. In 2020, 1.5 million people worldwide succumbed to TB, while an additional 10 million were infected with primary TB. However, major global health organizations agree that tuberculosis is both curable and preventable. For this reason, combating tuberculosis continues to remain at the forefront of global health efforts today.
The pathology of the TB is caused by Mycobacterium tuberculosis infection, which classically results in the development of granulomatous lesions in lung tissue. This disease can be latent, acute, or systemic/miliary in nature. Updated treatment protocols continue to recommend using derivations of the “RIPE” therapy regime for up to 6 months. The BCG vaccine is widely used in countries with high TB burden, providing strong protection against tuberculosis meningitis and miliary TB spread in children. However, this vaccine’s lack of effectiveness in adults and contraindication in both pregnant women and the immunocompromised has prompted the WHO to initiate new vaccine development. Additionally, the rising concern of multidrug-resistant TB has increased global efforts to establish new treatment options and a more effective vaccine.

Global health organizations have renewed their ambitions to mitigate the spread of TB. In 2014, the World Health Organization’s “End TB Strategy” set a goal to reduce TB incidence by 80% and death by 90% by 2030. The organization’s intention was to embolden local governmental policies and increase research efforts such as through the development of a new adult candidate TB vaccine, M72/AS01E. Similarly, the United Nations joined the WHO’s response by including the elimination of the tuberculosis epidemic on a list of 17 Sustainable Development Goals (SDGs) to be achieved by the year 2030. Despite these efforts, the progress made in battling TB has been halted by COVID-19. New cases of tuberculosis markedly fell in 2020 due to lack of access to diagnostic services, while global deaths increased for the first time in over a decade. The current COVID pandemic has also worsened prognostic outcomes of patients currently undergoing treatment for tuberculosis. Prior successes of global TB health policy, such as maintaining steady drug supply chain or providing healthcare personnel to assist with direct observation drug therapy, have been disrupted due to the economic and social implications of the current pandemic.
Since 2000, over 66 million lives worldwide have been saved through the diagnosis and successful treatment of tuberculosis. Despite dramatic setbacks caused by COVID-19, the global health community should remain optimistic about the long-term mitigation of this disease.

Discussion Questions:

• How can global health policies help to overcome the challenges caused by COVID-19 in the diagnosis and treatment of TB?

• How can healthcare professionals continue to further the progress made against TB burden in their own communities?

Journal Article: Five insights from the Global Burden of Disease Study 2019 Presented by Rachael Kantor

1. Double Down on Catch-up Development
Improvements in SDI have increased universally at an exponential rate since the 1950s. Originally (and predictably) we saw high SDI countries developing at a much faster rate than low SDI countries BUT since the start of the millennium counties of lower SDIs have been progressing at a rate much faster than those of high SDI statuses showing catch-up development. To close the gap, we must “double down” by increasing economic growth, expanding access to education, and improving the status of women in lower SDI countries. **Socio-demographic Index (SDI) is a measure used in the GBD to identify where a geographic area sits on the spectrum of development.
2. The Minimum Development Goal Health Agenda HAS been working
It’s no secret that since the early 2000s the global health community has focused heavily on decreasing mother and child mortality and decreasing the burden of communicable diseases (specifically TB, HIV, and malaria). The good new is these efforts have been incredibly successful BUT we owe it to ourselves to pay close attention to non-communicable disease (NCD) trends. Population growth and aging have led to a steady increased in NCDs.
3.Health Systems need to be more agile to adapt to the rapid shifts to NCDs and disabilities
As health profiles and SDI rankings change, universal health coverage must adapt to meet current health needs. This means increased focus on NCD coverage and greater attention to disorders causing functional health loss (MSK, substance abuse, mental health, etc.) to reduce the massive policy gap.
4. Public health is failing to address the increase in crucial global health risk factors
As global SDI has increased, many risk factors have seen a sharp decline. However, risk factors including High SBP, FBG, and BMI, as well as alcohol and drug use have increased alarmingly by > 0.5% a year.
5. Social, fiscal, and geopolitical challenges of inverted population pyramids
The GBD has estimated that by 2100 there will be over 150 countries whose death rate exceeds its birth rate; this compared to 34 countries in 2019. Many country populations will decrease—resulting in tremendous controversy regarding workforce maintenance, the ongoing immigration debate, and fertility incentivization2.

Discussion Questions:

•Many editorials/opinions call the neglect of chronic illness, and the exponential rise of preventable risk factors the “perfect storm” to fuel the COVID-19 pandemic. What sort of policies (concrete or abstract) should be put into place to take urgent action against this “failure of public health,” making countries more resilient to future pandemic threats?

•The authors of this study have concluded that exposure to/smoking tobacco has fallen 1-2% a year worldwide since 2010 due to the major efforts to implement international tobacco control policies rather than providing information to consumers about the harms of tobacco. However, the rate of exposure to other risk factors are increasing by more than 0.5% a year. Given the successes/failures of the efforts to decrease tobacco exposure, what place does government and international legislation have in the efforts to reduce these other risk factor exposures?

~This second discussion question provided an excellent conversation on the importance of individual autonomy and governmental policy influence, as well as those factors, including social determinants of health that limit both the individual and a government’s ability to take viable action to reduce risk factor exposure.

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings. Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Denise Manfrini, MS4

University of Florida

Andrew McAward, MS2

Marshall University, Joan C. Edwards School of Medicine

Rachael Kantor, MS4

The Medical School for International Health at Ben Gurion University

Sources and Further Reading:

Mukherjee, J. (2017). Chapter 4: Global Health and the Global Burden of Disease. In An Introduction to Global Health Delivery (pp. 89–105). book, Oxford University Press.
GBD 2019 Diseases and Injuries Collaborators. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 396, 1204–1222.
Global Health CEA registry database with publications from different countries about cost-saving interventions – https://cevr.shinyapps.io/LeagueTables/
Kant, Surya, and Richa Tyagi. “The Impact of Covid-19 on Tuberculosis: Challenges and Opportunities.” Therapeutic Advances in Infectious Disease, vol. 8, 9 June 2021, p. 204993612110169., https://doi.org/10.1177/20499361211016973.
Kirby, Tony. “Global Tuberculosis Progress Reversed by COVID-19 Pandemic.” The Lancet Respiratory Medicine, 2 Nov. 2021, https://doi.org/10.1016/s2213-2600(21)00496-3.
Roy, A., et al. “Effect of BCG Vaccination against Mycobacterium Tuberculosis Infection in Children: Systematic Review and Meta-Analysis.” BMJ, vol. 349, no. aug04 5, 2014, https://doi.org/10.1136/bmj.g4643.
“Tuberculosis (TB).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 25 Oct. 2021, https://www.cdc.gov/tb/default.htm.
“Tuberculosis (TB).” World Health Organization, World Health Organization, 14 Oct. 2021, https://www.who.int/news-room/fact-sheets/detail/tuberculosis.
GBD 2019 Viewpoint Collaborators. Five insights from the Global Burden of Disease Study 2019. Lancet. 2020 Oct 17;396(10258):1135-1159. doi: 10.1016/S0140-6736(20)31404-5. PMID: 33069324; PMCID: PMC7116361.
Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet. 2020; 396: 1160-1203

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Emergency Medicine Perspectives of Students – Europe

November 22, 2021November 20, 2021 ~ Arif Alper Cevik ~ Leave a comment

Dear EM family,

The International Emergency Medicine Education Project (iem-student.org) has completed three years. As you may know, the iEM Education project aims to promote Emergency Medicine and provides copyright-free resources to students and educators around the world. Now we have reached more than 200 countries. We would like to thank again our contributors. Without them, such a project would not be possible. This experience has shown us once again how passionate our international EM community is to help and teach each other.

In May 2021, we started the fourth year of this journey. To celebrate, we are pleased to announce alive activity series, Emergency Medicine Perspectives of Students Around the World. Our guests for the third session are Nadine Schottler from UK, Helena Halasaz from Hungary, and Gregor Prosen from Slovenia.

Together, we can understand the experiences and needs of medical students from different backgrounds and discuss potential solutions.

Here are the video and audio records of this session.

iem-student.org · Emergency Medicine Perspectives of European Students

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Emergency Medicine Perspectives of Students – World

November 10, 2021October 14, 2021 ~ Arif Alper Cevik ~ Leave a comment

Dear EM family,

In May 2021, we started the fourth year of this journey. To celebrate, we are pleased to announce alive activity series, Emergency Medicine Perspectives of Students Around the World. Our guests for the second session are Maryam Zadeh from Canada, Nawaf Alamri from Saudi Arabia, and Rebeca Barbara from Brazil, who are the leaders of the International Student Association of Emergency Medicine..

Together, we can understand the experiences and needs of medical students from different backgrounds and discuss potential solutions.

Here are the video and audio records of this session.

iem-student.org · ISAEM – EM Perspectives Of Students Around The World

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Journal Club 10-04-21 : Health Equity, Medical Tourism, and Maternal Mortality in LMICs

November 1, 2021October 30, 2021 ~ Global EM Student Leadership Program ~ Leave a comment

Welcome back! The first GEMS LP journal club of the season took place on October 4th, 2021. During each meeting, we discuss a journal article, a global health clinical topic, and a book chapter from one of two books: An Introduction to Global Health Delivery by Joia Mukherjee or Reimagining Global Health: An Introduction by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico.

The goal of journal club is to expose our mentees to fundamental global health concepts and their applications in the real world. Having a diverse cohort of participants allows for lively and engaging discussion based on each participants’ life experiences. Below is a summary of each section presented at journal club. Be sure to join us at our next meeting, taking place November 8th, 2021.

Many of the global health disparities that exist today are a result of centuries of exploitation of developing countries that can trace its roots to the slave trade. As slavery ended in the 19th century, the extraction of people was replaced with the extraction of resources as European nations divided up Africa amongst themselves. By the 20th century, centuries of exploitation had robbed newly independent countries of the resources needed to provide healthcare for their citizens. Newly liberated countries came to rely on Western monetary institutions for loans, which often came with strings attached. Loans from the World Bank and the International Monetary Fund limited the amount of public expenditures on vital healthcare infrastructure, medication, and personnel. Healthcare in developing countries was further undermined by the neoliberal policies promoted by Western countries beginning in the 1980s. Developing countries were compelled to fund healthcare through above-cost user fees, which reinforced unequal access to care and widened healthcare inequality. The neoliberal approach also championed the concept of sustainability, which focused on low-cost preventative care instead of treatment. By the 1990s, this approach had led to widening healthcare inequity between the developed and developing worlds.

Discussion Questions:

·Reflect on prior medical service trips you may have gone on or may be offered by your university. In what ways do these trips reflect the legacy of colonialism? How can we “de-colonize” global health in medical education?

·Should all medical interventions in lower-income and developing countries be “sustainable”?

Medical tourism is a modern practice in healthcare that is exacerbating global health inequity. For centuries, people of higher socioeconomic classes commonly visited higher developed countries to receive care for their medical ailments. Their journeys are much more expensive than an ordinary citizen could afford but with the advent of air travel and a rapid development of the middle class with a larger share of disposable income, many more people are travelling for medical services today than ever before. The propagation of medical tourism is exacerbating the divide in quality of care in developing countries. As private hospitals primarily attract international patients, they attract more doctors with higher salaries and benefits paid for by medical tourists’ bills. This develops a positive feedback loop that continues to neglect the care of the poorest patients who need the most advanced care and rely on public hospital systems that are already overburdened. Rather than focusing on bettering the care of public hospitals and working for the native populations, private hospital systems and governments encouraging medical systems are further dividing the health gap between socioeconomic classes and contributing to health inequity.

Discussion Questions:

• What are some ethical issues developed by private healthcare systems motivated by financial incentives?

• How can medical professionals in our country educate patients about the risks of medical tourism?

Global health disparity is apparent in the care of pregnant individuals, with 94% of all maternal deaths occurring in low and lower-middle-income countries. A leading cause of maternal and perinatal mortality in these regions is hypertensive disorders of pregnancy, especially pre-eclampsia and its spectrum of diseases. Crucial to the screening and diagnosis of these disorders are regular antenatal care and assessment of risk factors, such as advanced maternal age, obesity, diabetes, and existing hypertension. For pre-eclampsia and eclampsia, the WHO has released evidence-supported recommendations for both preventative measures, such as calcium supplementation in areas with low intake, and treatment, such as using magnesium sulfate over other anticonvulsants. In low resource settings, some of the barriers that hinder the care of pregnant individuals with hypertensive disorders are a shortage of specialty-trained healthcare workers, inadequate transportation to healthcare facilities, limited antenatal care, and traditional cultural practices. While much work still needs to be done in tackling many of these challenges, especially in improving basic obstetric emergency treatment at primary community settings, innovative strategies such as task-shifting to train community health workers (CLIP initiative) in providing regular antenatal care and community cost-sharing schemes to eliminate financial barriers to obstetric care in Mali have been shown to have positive outcomes.

Discussion Questions:

· What other non-health related barriers may contribute to maternal mortality?

· What roles can emergency services/emergency medicine physicians play in improving the outcome of obstetric emergencies?

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings, the next of which is taking place November 8th, 2021. Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Brian Elmore, MS4

Medical University of South Carolina

Jai Shahani, MS2

Rutgers New Jersey Medical School

Luxi Qiao, MS4

Washington University School of Medicine

Sources:

Mukherjee, Joia. “Chapter 1: The Roots of Global Health Inequity.” An Introduction to Global Health Delivery: Practice, Equity, Human Rights, Oxford University Press, New York, NY, 2018.
Mutalib, Nur & Ming, L C & Yee, Esmee & Wong, Poh & Soh, Yee. (2016). Medical Tourism: Ethics, Risks and Benefits. Indian Journal of Pharmaceutical Education and Research. 50.
261-270. 10.5530/ijper.50.2.6.
http://ijper.org/sites/default/files/10.5530ijper.50.2.6.pdf
WHO. Maternal mortality evidence brief, 2019.
WHO. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia, 2011.
Fournier P, Dumont A, Tourigny C, Dunkley G, Drame S. Improved access to comprehensive emergency obstetric care and its effect on institutional maternal mortality in rural Mali. Bull World Health Organ 2009; 87: 30-8
von Dadelszen P, Vidler M, Tsigas E, Magee LA. Management of Preeclampsia in Low- and Middle-Income Countries: Lessons to Date, and Questions Arising, from the PRE-EMPT and Related Initiatives. Maternal-Fetal Medicine 2021; 3(2): 136-50.
Firoz T, Sanghvi H, Merialdi M, von Dadelszen P. Pre-eclampsia in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2011; 25: 537-48.
Milne F, Redman C, Walker J, et al. The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community. BMJ 2005; 330: 576-80.

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Emergency Medicine Perspectives of Students – Africa

October 27, 2021October 14, 2021 ~ Arif Alper Cevik ~ Leave a comment

Dear EM family,

In May 2021, we started the fourth year of this journey. To celebrate, we are pleased to announce live activity series, Emergency Medicine Perspectives of Students Around the World. Our guests for the first session are Adebisi Adeyeye from Nigeria, Jonathan Kajjimu from Uganda, and Mohamed Hussein from Egypt, who are Student Council Leaders of the African Federation for Emergency Medicine.

Together, we can understand the experiences and needs of medical students from different backgrounds and discuss potential solutions.

Here are the video and audio records of this session.

iem-student.org · IEM Live – EM Perspectives Of Students Around The World – Africa

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The State of Emergency Medicine in Ecuador

September 18, 2021September 15, 2021 ~ Global EM Student Leadership Program ~ Leave a comment

Ecuador is fast approaching its 30^th anniversary of recognizing emergency medicine as a specialty. Within these three short decades, the country has achieved significant milestones in advancing the field of emergency medicine, including the development of a national EM society and implementation of post-graduate training programs. However, there is still much work to be done. I was lucky enough to have a conversation with the ACEP Liaison to Ecuador, Augusto Maldonado, to learn of recent advancements of emergency medicine in the country.

“Igual que todos los países del mundo, el rol los que responden inicialmente y la organización de los servicios de emergencia frente a esta emergencia de salud ha sido muy especial.”

The COVID-19 pandemic certainly affected the specialty in the scope of medical practice, as well as highlighted some of the limitations of the medical system that were already present. Following the global trend, emergency care providers came to the forefront of medical attention with the manifestation of the pandemic. Dr. AM says that many emergency departments were forced to adapt in the face of the pandemic, as some hospitals became designated ‘COVID hospitals’ requiring emergency departments to coordinate care for the remaining patients. For example, some emergency physicians suddenly found themselves providing postoperative care when patients would be transferred directly from surgery back to the emergency department. In other places, emergency departments were transformed into intensive care units, staffed by emergency physicians. Dr. AM explains that the COVID-19 pandemic has given the specialty the push it needs, stating “ . . regarding the issue of the pandemic, it really has given us a very big boost as a specialty and I believe that to the authorities it is now very clear the importance of emergency medicine as a specialty to face this type of complex situation”.

This increased visibility of the specialty is mirrored by the substantial popularity of the country’s national emergency medicine society, Sociedad Ecuatoriana de Medicina de Emergencias, which has increased in number by over 500%!

The country has also seen an increase in the number of residency training programs over the last year. In addition to the two already running in Quito, a third and fourth have been established in the city of Cuenca, and a fifth is set to open in Guayaquil. Furthermore, a critical care fellowship is in the works at Universidad San Francisco de Quito. This project stems from a recent study which identified a high demand for a critical care fellowship in Ecuador.

The impact of COVID on trainees’ education has, thankfully, not been substantial. Unfortunately, the pandemic did result in residents not being recruited to the Quito programs for 2020, but the programs in Cuenca did start a new class of trainees last year. As with many training institutions across the world, the residents were initially barred by the health authorities from treating COVID patients. However, the creation of ‘COVID’ and ‘mixed’ hospitals has resulted in an increased workload for residents serving the non-COVID population – “I believe that the residents have more work than before . . . and have more procedures because of the overhang generated by the creation of ‘mixed’ hospitals. There’s a lot to do.” He states that residents are on-track for completion of their programs, with ample procedures logged to graduate.

Another aspect of residency training is the required completion of a scholarly project. Research has been slowed across the country as a result of the pandemic. Interest in COVID investigations sparked the Ministry of Health to establish an ADHOC committee explicitly tasked with expediting the review of research proposals. The committee was mandated to review proposals within five days of submission, but in reality, approvals are taking upwards of three to four months. La Universidad San Francisco de Quito explored this roadblock and revealed that some twenty studies had been published through alternative review processes due to the lengthy process of gaining official approval. Dr. AM views COVID as a potential kick-start for encouraging providers to do research, saying “I see it as a great opportunity to better focus [on] research, which is one of the things that we have been looking to do for a long time . . . with the pandemic, [we see] the importance of doing clinical research [in being] able to give adequate treatment to our patients.”

Looking forward, Dr. AM says that there are many remaining opportunities for growth in the field of emergency medicine, much of which he hopes can be better addressed once the economic situation in Ecuador recovers. He says there is much desire for innovation within the field, but many EM providers are having to work two to three jobs to have a sufficient income to live, leaving little time for research, teaching, or collaboration. There are many lessons to be learned world-wide from the pandemic, but Dr. AM says that in order to address future issues international cooperation is key.

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Halley J. Alberts, MD

Halley is a first year resident training in Emergency Medicine at Prisma Health - Midlands at the University of South Carolina. She was a GEMS LP mentee for the class of 20-21 and has now joined the leadership team by managing the new GEMS LP blog page and assisting with journal club.

Welcome from GEMS LP!

September 16, 2021October 24, 2021 ~ Global EM Student Leadership Program ~ Leave a comment

Hello and welcome to the first blog post from ACEP’s International Section’s Global Emergency Medicine Student Leadership Program. We are thrilled to partner with iEM in the hosting of this blog, and we thank them for their collaboration and enthusiasm.

Global EM is a young, quickly growing field in the world of health care, but there remains much work to be done. The GEMS LP program was designed to involve students in this exciting and fulfilling specialty. The program itself falls under ACEP’s International Section in conjunction with the International Ambassador Program. All of these entities share a common goal: the advancement of the emergency medicine specialty worldwide.

Through this blog, we hope to educate, inspire, update, and collaborate on all things global EM. Every couple of weeks, you can expect to read the ‘key points’ from our journal clubs. In each meeting, we review fundamental global health topics through a book chapter and a research paper, followed by a dynamic discussion with a diverse group ranging from medical students to attendings, working both in the US and abroad. Additionally, you can look forward to interviews with some of ACEP’s International Ambassador team members, interesting case discussions, GEMS LP project highlights and other fun commentaries from our mentees and team!

We look forward to providing you relevant content that will encourage discussion, contemplation, and promotion of the field of global emergency medicine. Thank you for joining us on this new adventure! Please visit our page (https://iem-student.org/gems-lp/) for more information about our leadership team, awesome mentors, and upcoming events and meetings.

Comments, suggestions, additions? Please reach out to us!

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What is Emergency Medicine?

May 3, 2021April 3, 2021 ~ J. Austin Lee, USA ~ Leave a comment

I recently have been working on a few different projects that have caused me to stop and reflect, “what is emergency medicine”. This specialty is very young within the house of medicine, compared to most other medical specialties. And while other specialties developed out of an attention to anatomical region or approach to diagnosis and treatment, emergency medicine has developed in large part to fill a gap in the healthcare workforce and address a specific needed skillset within healthcare systems.

Different health systems around the world have different structures and models of care. Some countries have developed robust primary health care systems with universal coverage for all citizens, while others have adopted alternative models of preventative and acute care. There is even greater diversity in how individuals seek and receive care for urgent and emergent health needs. The spectrum of the quality and availability of emergency care often varies within countries as well, contrasting highly populated urban centers against rural communities, or between different counties/provinces.

As a frame of reference, emergency medical care is any unscheduled episode of care for an acute health problem. It should be available 24 hours a day and systems should aim for patients to be dispositioned to inpatient units, taken to the operating room/theater, or discharged for outpatient care. Ideally, patients should spend less than 24 hours in the emergency ward, it is meant to be a short-term waypoint for diagnosis, treatment, and disposition. The skills and approach to emergency care are focused on the initial management, stabilization, and resuscitation of ill patients, as well as making targeted diagnostic and treatment decisions. Emergency care units shouldn’t be built to do any and all testing and treatment, but should complement other care pathways within the health system.

In much of the world the emergency ward is the most common entry point to hospitals and inpatient care. And specialized training in emergency medicine improves the quality of patient care with associated reductions in morbidity and mortality. Emergency medicine providers must be capable of treating all age groups, across undifferentiated and potentially routine or life-threatening patient presentations. And yet, there are days when an emergency medicine provider may not encounter any patients with a true life-threatening emergency, but rather may only see patients with a variety of complaints that exist here and now, and require attention to limit longer-term morbidity or mortality. Conversely, other days may have multiple critically-ill patients all at once. Usually, those attracted to emergency medicine enjoy the diversity of presentations, and it would seem almost no two days at work are the same.

As alluded to above, the emergency departments existed as a triage ward quite some time before the development of a specialized education and training in emergency medicine. And in many emergency care wards around the world today, patients are seen by students or junior doctors with little interest or training in emergent medical conditions. It is also important to remember that most emergency department patients are undifferentiated and evaluating a patient for causes of a single complaint requires a thorough history, exam, and targeted diagnostic testing. This skill set is how an emergency medicine provider can assess a patient who presents with chest pain and distinguish a myocardial infarction from a pulmonary embolism from musculoskeletal pain. To me, this is the real benefit of emergency medical education and specialized care: there are so many treatments and disposition pathways any singular chief complaint can lead to.

But, most anyone reading this post is likely familiar with the need for improved emergency care around the world. And as more countries recognize emergency medicine as a specialty and as more individuals decide to dedicate their career to providing high-quality emergency medical care, the global (and local) standards will continue to improve. An ever-growing body of evidence-based care continues to refine when and how we care for different conditions. And it’s so important that we continue to address the multitude of “unscheduled” health needs for our patients. Continue to adapt emergency medicine to your context and improve the care for your patients; as one of the most well-known EM-education podcasters often says: “what you do matters”.

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Recent Blog Posts By John Austin Lee

Out of Proportion: Acute Leg Pain

What is Emergency Medicine?

Local Anaesthetic Toxicity (LAST)

COVID-19; Reflecting on a Globalized Response

Trauma and Public Health

Basic Emergency Care (BEC): A New Global Health Framework

Illness Narratives In Global Health

April 5, 2021February 28, 2021 ~ Nardos Makonnen, USA ~ Leave a comment

Storytelling is a powerful tool that allows us to relate to one another across borders, cultures, and experiences. It is a significant aspect of global health. Images associated with international health are those of pediatric patients in low and middle-income countries (LMICs) with descriptions of ailment or news stories on television of an outbreak in a faraway country. These stories capture our attention and allow us to process situations far removed from ours. While stories allow us to communicate the urgency and extent of international health topics, there are challenges associated with illness narratives. It is important to examine how stories are told in medicine, and specifically in global health. It is critical to question who tells stories, how they’re told, and what their impact is. These can be stories of individual patients in a country, medical aid organizations, or even stories of a country’s health infrastructure.

A recent Lancet essay titled “Global Health 2021: Who tells the Story” examines the role of journals when it comes to research in academic global health. The essay cites data showing a lower number of publications authored by those affiliated with or came from LMIC in The Lancet Global Health(1). Here, the authors reflect on how, as a London-based global health journal, they need to examine the narration disparities. They note that an imbalance in authorship is a symptom of an imbalance in power when it comes to academic global health.

This essay was in part motivated by a crucial article by Seye Abimola and Madhukar Pai. In their article examining the decolonization of global health, Abimola and Par state “even today, global health is neither global nor diverse. More leaders of global health organisations are alumni of Harvard than are women from low-income and middle-income countries. Global health remains much too centred on individuals and agencies in high-income countries (HICs).”(2) This important point highlights the distance between the subject of stories and those who tell them. This can limit diversity in perspective while taking away ownership of stories from those who experience it.

An article looking at illness narratives in an outbreak reported that when it comes to Ebola, Zika, and SARS, marginalized communities often bear the burden of disease while their account of illness is often neglected. The authors state, “regardless of income setting, there is a need to give voice to the most marginalized communities during an epidemic.”(3) This point on narration should extend beyond authorship in research to include news coverage of global health events. The way the Ebola outbreak and even early days of COVID pandemic were portrayed are examples of the dangers associated with lack of nuance in the way global health topics are discussed in the media.

Inclusivity of illness narratives around global health can allow us to avoid pitfalls that lead to widespread misinformation and discrimination. In addition to examining who tells the story, it is also important to explore how stories are told. An essay highlighting the challenges of storytelling in medicine notes that at times the trauma of subjects has been exploited by international charities. The article states the importance of communicating stories in a way that does not “feast on the trauma of others”(4).

At the core of his argument is the need to examine how we communicate the stories of others. As described above, allowing locals to tell stories regarding their experience of illness, outbreaks, and research can help us deal more carefully with the associated trauma. Stories told without careful consideration can lead to widespread misinformation and potentially harmful generalizations. As we move towards examining how we improve global health delivery, it is critical to explore how we can improve the stories we share. In order to create a better system to communicate important global health topics, it is imperative to challenge the ways we receive information constantly.

This will broaden our understanding of complex issues and allow us to consider alternative solutions.

To this end, the following five questions should help us navigate the challenges of global storytelling. These questions are suggested to help guide our approach towards a more

Has the subject given informed consent to tell their story?
How is the story presented?
Is there a way to allow the story subject to be
Do the stories told reinforce harmful stereotypes?
Are there negative consequences to the subject if the story is told?

References and Further Reading

Health TLG. Global health 2021: who tells the story? The Lancet Global Health. 2021;9(2):e99.
Abimbola S, Pai M. Will global health survive its decolonisation? The Lancet. 2020;396(10263):1627-1628.
Kapiriri L, Ross A. The politics of disease epidemics: a comparative analysis of the sars, zika, and ebola outbreaks. Glob Soc Welf. 2020;7(1):33-45.The
Harman S. The danger of stories in global health. The Lancet. 2020;395(10226):776-777

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