Journal Club 11/29/21: Ethics of Humanitarian Work

POCUS in Resource-Limited Settings presented by Holly A. Farkosh

POCUS, or point-of-care ultrasound, is a focused exam performed and interpreted by an examiner usually at the bedside, that must answer a specific question (is there a pleural effusion, yes or no?). The diagnosis must also be 1) relevant to consecutive treatment decision-making and 2) easily and accurately recognizable by the physician applying the US without extensive training.

There are many advantages to using POCUS in a resource-limited setting, including but not limited to: 

– Portability; relatively inexpensive starting at $2000

– Limited access to other diagnostic imaging equipment (XR, CT, MRI–all of which require additional training to read and use/operate)

– Rapid, noninvasive

– No ionizing radiation exposure

– Improves success and safety of bedside procedures

– Can easily be repeated, quickly, and without increasing radiation exposure, especially if clinical status or physical exam findings change 

– Particularly cost-effective (in the United States) in pediatric appendicitis and trauma (found to have decreased time to OR, decreased CT scans in the pediatric population, shortened length of hospital stay)

Some of the disadvantages include:

– Requirement of formal training

– Issue of how to power/charge and reliable access to this

– Handheld US requires a smartphone

– Supplies (US gel)

– Upkeep and repair

– Image portability (inability to print or save images for patients to share with other healthcare providers)

– Ethical considerations? 

Tying it all Together: Ethical Considerations for POCUS in Resource-Limited Settings

– Cost-effectiveness: some resources are deemed too expensive

– Resource limitations and differences in standard of care between the United States and other countries 

– Practitioners who may be teaching US may have limited knowledge of practicing in resource-limited settings, or there may be discrepancies in both knowledge of using the technology/resources available as well as the common presenting diseases in that region

– Sustainability: in relation to implementing training programs– what happens after instructors leave? Requires adequate planning for system integration and ongoing supervision and skill maintenance

– Limited capacity and inconsistent availability of follow-up care; screening without available treatment

Discussion Questions:

  • What other ethical considerations are there to implementing POCUS in resource-limited settings?

       – Advantage: lack of need for significant infrastructure; skills can quickly be acquired; real-time video training/support between the United States and other countries

        – Limited support for continued supervision/continual mentorship on improving skills; sustainability of training programs

        – Potential costs of training

  • What to do when you come across findings not consistent with physical exam– how to advocate for further diagnostics/evaluation?
  • Using US for central lines: lack of US availability; no formal US training; need to teach how to use US, but also important to teach things such as sterile prep/technique

Why do we have a desire to work in Global Health? By Cody Ritz

Chapter nine from Reimagining Global Health: An Introduction aims to explore a few different answers to this complex question. It’s possible that many of our desires to work in Global EM stem from some of the moral frameworks or values systems presented in these pages. The chapter lays them out as such:

Depending on your own personal motivations, you may identify with one, many, or none of these moral frameworks or value systems. This list is not meant to be exhaustive, and it barely scratches the surface of the many nuances included in each of these philosophies. While we could go to much greater lengths to wholly explore these schools of thought, I believe the greatest benefit in naming them is not solely for the purpose of categorization. Rather, by taking the time to compare these sources of motivation, we can equip ourselves with a vocabulary and mindset that helps give form to our innermost determinations. While this form develops, we can begin to understand the foundations of our own interest to work in not only global health but medicine at large. As we come to better understand ourselves, let us hope this allows us to better understand others as well.

Discussion Points:

  • With which of these frameworks/value systems do you identify personally? – One? Multiple? None of them at all? – and how has that framework informed your own perspective and approach to global health?
  • Imagine that you’re in an interview for a position you want in the future and the interviewer asks—Why do you have these interests in global health when there is already great need within your own backyard?— How do you respond? In what ways could you explain your motivations within the frameworks discussed in this chapter?

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!

Holly Farkosh, MS4

Holly Farkosh, MS4

Marshall University School of Medicine

Cody Ritz, MS2

Cody Ritz, MS2

Drexel University College of Medicine

Keep in Touch:

Cite this article as: Global EM Student Leadership Program, "Journal Club 11/29/21: Ethics of Humanitarian Work," in International Emergency Medicine Education Project, April 6, 2022, https://iem-student.org/2022/04/06/journal-club-11-29-21-ethics-of-humanitarian-work/, date accessed: July 4, 2022

Journal Club 11/08/21: Resource Equity in a Pandemic

The Global Burden of Schistosomiasis presented by Farah Mechref

Endemic in 74 countries across Africa, the Middle East, South America, and Asia, schistosomiasis is a neglected tropical disease caused by flatworms or blood flukes known as schistosomes. About 440 million individuals are infected with these trematodes, which reside in the blood vessels of their definitive host and lead to different clinical manifestations depending on the species. In regions endemic for schistosomiasis, the most prevalent form of the disease is
chronic schistosomiasis, resulting from repeated immunological reactions to eggs trapped in organ tissues. Infection begins when individuals enter bodies of water that contain contaminated snails that have released infectious cercariae. These cercariae penetrate the skin of the human host and produce an allergic dermatitis at the site of entry or a “swimmer’s itch.” Antigens are then released from their eggs, which stimulates a granulomatous reaction composed of T cells, macrophages, and eosinophils, resulting in the clinical disease. 

Acute schistosomiasis typically presents with sudden onset of fever, malaise, myalgia, headache, fatigue, and abdominal pain lasting 2–10 weeks, with eosinophilia noted on lab findings. Chronic infection cause granulomatous reactions and fibrosis in affected organs, which results in clinical manifestations
that include: 

-In S. mansoni and S. japonicum: upper abdominal discomfort that then shows palpable, nodular hepato-spenlomegaly with eventual development of portal hypertension from fibrosis of portal vessels and resulting ascites and hematemesis from lethal esophageal varices.

-In S. haematobium: hematuria, which is so endemic that it’s thought to be a natural sign of puberty for boys and confused with menses in girls, with eventual development of squamous-cell carcinoma of the bladder.

Currently, the only control measures available include (1) mass treatment with Praziquantel (Biltricide) in communities where schistosomiasis is endemic, (2) introduction of public hygiene programs to provide safe water supplies and sanitary disposal of stool and urine, (3) snail eradication programs using molluscicides, and (4) vaccination development to create a more durable and sustained reduction in transmission.

Discussion Questions:

  • Knowledge of transmission and preventative measures play an important role in schistosomiasis control, what other endemic conditions could be better tackled with improved patient education?
  • With 230 million actively infected patients and another 200 million with latent infections, is a vaccine worth the resource distribution or should funding go towards expanding the anti-parasitic classes available for treatment? 

Resource Equity in a Disease Outbreak by Alison Neely

The Ebola virus disease of 2013-2016, centered in West Africa, was considered one of the most threatening cases of infectious disease outbreak in modern history up until the emergence of Covid-19 in 2019. Due to the high case fatality rate of Ebola, the core element of the outbreak response was effective case identification and rapid isolation; treatment centers were quickly overwhelmed and experienced limited bed supply and staff time. A study drawing from interviews with senior healthcare personnel involved in this Ebola outbreak response aimed to identify the ethical issues involved in such a response and to create a framework of ethical guiding principles for future responses.

The framework proposed after analysis of the participants’ interviews was split into four categories: community engagement, experimental therapeutic interventions, clinical trial designs and informed consent. Community engagement stood out as a key element both in the framework and in the journal club discussion that followed. Engagement can include promotion of collaboration and open dialogue, incorporation of community insights into decision-making processes, encouragement of transparency, building trust, and reflecting on context-specific cultural values. As future physicians with special interest in global medicine, these ideas of respecting cultural context and complete inclusion of the local community in response efforts were highlighted as very relevant to our future practice.

Discussion Points:

  • Have the principles presented here been followed in the global response to the Covid-19 pandemic?
  • Our discussion also focused on the parallels and differences between this Ebola response and the global response to the Covid-19 pandemic, calling attention to the ways that the response both followed and diverged from the framework presented in this article. As the idea of a disease outbreak has become part of daily conversation in the last 2 years, investigations and discussions such as this will become increasingly relevant and important. We also touched on the idea that our global response to Covid-19 may have been very different, and potentially weaker, if the Ebola outbreak had not occurred when it did.
 

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!

Farah Mechref, MS4

Farah Mechref, MS4

Texas Tech University Health Sciences Center

Alison Neely, MS4

Alison Neely, MS4

Albert Einstein College of Medicine

Keep in Touch:

Cite this article as: Global EM Student Leadership Program, "Journal Club 11/08/21: Resource Equity in a Pandemic," in International Emergency Medicine Education Project, February 23, 2022, https://iem-student.org/2022/02/23/resource-equity-in-a-pandemic/, date accessed: July 4, 2022

Journal Club 10/18/21: The Global Burden of Disease

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.

Change in worldwide burden of disease from 1990 to 2019. Red - infections/perinatal/maternal conditions; Blue - noncommunicable disease; Green - Injuries/accidents. Source: 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.

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

Denise Manfrini, MS4

University of Florida

Andrew McAward, MS2

Andrew McAward, MS2

Marshall University, Joan C. Edwards School of Medicine

Rachael Kantor, MS4

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

 

Keep in Touch:

Cite this article as: Global EM Student Leadership Program, "Journal Club 10/18/21: The Global Burden of Disease," in International Emergency Medicine Education Project, December 13, 2021, https://iem-student.org/2021/12/13/journal-club-the-global-burden-of-disease/, date accessed: July 4, 2022

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

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.

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.

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

Brian Elmore, MS4

Medical University of South Carolina

Jai Shahani, MS2

Jai Shahani, MS2

Rutgers New Jersey Medical School

Luxi Qiao, MS4

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.

 

Keep in Touch:

Cite this article as: Global EM Student Leadership Program, "Journal Club 10-04-21 : Health Equity, Medical Tourism, and Maternal Mortality in LMICs," in International Emergency Medicine Education Project, November 1, 2021, https://iem-student.org/2021/11/01/health-equity-medical-tourism-and-maternal-mortality-in-lmics/, date accessed: July 4, 2022

Special Considerations for Homeless Patients in the Emergency Department

The emergency department is often the first place that a homeless patient steps into to seek medical aid, and as such, the special considerations in the care of this particularly vulnerable patient population is an important discussion for aspiring emergency medicine physicians.

In 2017, a YaleGlobal article estimated that there were approximately 1.5 million homeless people worldwide, which made up 2% of the global population at the time. In the same report, they noted that an estimated 1.6 billion people lacked “adequate housing,” which unfortunately has no specific definition and thus varies from country to country, as well as from study to study.1

Nevertheless, it is apparent that the numbers are staggering. For an in-depth overview of the statistics relating to homeless on a global scale, Wikipedia offers a list of countries by homeless population, linked here.2 Many of these individuals do not have easy access to maintenance healthcare and end up resorting to emergency services for both acute and non-acute issues.

Numerous studies have shown that homeless patients are generally high utilizers of emergency services; according to the Center for Disease Control in the United States, there was an annual average of 42 ED visits per 100 non-homeless people between 2015-2018, compared to an average of 203 ED visits per 100 homeless persons in the same timeframe.3

So the question becomes: what are some of the special considerations that we, as emergency medical staff, should be weighing when treating homeless patients? Here are some tips:

  1. Start thinking about disposition early, and, if your facility has access to them, get social workers involved as soon as possible. Take into consideration the closing time(s) of nearby shelters, and plan accordingly.
  2. Discuss and document your patient’s social history thoroughly; this can not only help whatever further research that may be conducted but also help build better rapport with your patient. Ask whether they live in a shelter or on the street, for how long, transportation needs, etc., and be sure to document key findings.
  3. Evaluate ability to perform activities of daily living, assess the level of functional independence and ambulatory capabilities.
  4. Provide clothing, food, warm blankets, and mobility devices, when appropriate.
  5. Assess access to follow-up healthcare. Familiarize yourself with the resources available: what are the organizations in your area that might be of help? Are there non-profits that work explicitly with the homeless population?
  6. Discuss any potential substance abuse and attempt counseling.*

* In the United States, consider obtaining an x-waiver, which would allow you to prescribe buprenorphine. For more information about the significance of the x-waiver and information on how to obtain one online for free, click here.

  1. Prepare discharge papers with clear, easy-to-understand instructions for follow-up and care. Avoid medical jargon and use comprehensible language; one recommendation suggests keeping language to a fifth-grader level.

Areas of improvement:

Each institution that deals with homeless patients will likely have its own protocols in place for its management. It is helpful to get acquainted with these protocols and to look around your emergency department to see if there is any room for improvement.

Below are some of the interventions which were undertaken, many of which ultimately showed a reduction in re-presentation and ED utilization, and could lead to an increase in patient satisfaction.

  • transition of care: a review examining the effect of various interventions in discharging homeless patients found that all three studied categories (those being case management, individualized care plans, and information sharing) had a modest impact, with varying degrees of success based on different studies.4
  • dedicated homeless clinics: a single-center study in 2020 found that a dedicated homeless clinic initiative reduced ED disposition failures and inappropriate ED visits, defined as seeking care for non-emergent conditions.5
  • transportation considerations: while some hospitals are able to subsidize travel costs (taxi vouchers, shuttle service, etc.), that might not be possible at all institutions, so alternatives should be considered.

[A 2012 community-based participatory research approach was undertaken to understand how homeless patients (n = 98) reflected on their care. Of the patients surveyed, 42% mentioned that there had been no discussion of transportation, while 11% noted that they had slept on the street the night after discharge.6 This goes to show how important it is to discuss disposition early and thoroughly.]

  • adding social determinants into electronic medical record-keeping systems: a paper reflected on the changes, such as adding fields for social determinants to the electronic health record (EHR) system, that were undertaken in Hawaii, USA.7 Some institutions tag their homeless patients in a certain way, but making changes at the EHR level could help integrate social needs into clinical care across multiple providers.

References and Further Reading

  1. Chamie J. As Cities Grow Worldwide, So Do the Numbers of Homeless. YaleGlobal Online. https://truthout.org/articles/as-cities-grow-worldwide-so-do-the-numbers-of-homeless/. Published 2017. Accessed June 8, 2021.
  2. Wikipedia. List of countries by homeless population. Wikipedia. https://en.wikipedia.org/wiki/List_of_countries_by_homeless_population#cite_note-1. Accessed June 8, 2021.
  3. QuickStats: Rate of Emergency Department (ED) Visits, by Homeless Status and Geographic Region — National Hospital Ambulatory Medical Care Survey. MMWR Morb Mortal Wkly Rep. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a8.htm. Published 2020. Accessed June 8, 2021.
  4. Soril LJJ, Leggett LE, Lorenzetti DL, Noseworthy TW, Clement FM. Reducing frequent visits to the emergency department:A systematic review of interventions. PLoS One. 2015;10(4):1-18. doi:10.1371/journal.pone.0123660
  5. Holmes CT, Holmes KA, MacDonald A, et al. Dedicated homeless clinics reduce inappropriate emergency department utilization. J Am Coll Emerg Physicians Open. 2020;1(5):829-836. doi:10.1002/emp2.12054
  6. Greysen SR, Allen R, Lucas GI, Wang EA, Rosenthal MS. Understanding transitions in care from hospital to homeless shelter: A mixed-methods, community-based participatory approach. J Gen Intern Med. 2012;27(11):1484-1491. doi:10.1007/s11606-012-2117-2
  7. Trinacty CM, LaWall E, Ashton M, Taira D, Seto TB, Sentell T. Adding Social Determinants in the Electronic Health Record in Clinical Care in Hawai’i: Supporting Community-Clinical Linkages in Patient Care. Hawaii J Med Public Health. 2019;78(6 Suppl 1):46-51. http://www.ncbi.nlm.nih.gov/pubmed/31285969http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC6603884.
Cite this article as: Helena Halasz, Hungary, "Special Considerations for Homeless Patients in the Emergency Department," in International Emergency Medicine Education Project, July 5, 2021, https://iem-student.org/2021/07/05/special-considerations-for-homeless-patients-in-the-emergency-department/, date accessed: July 4, 2022