Almost 16 years after being in the United States of America as a physician, we visited our birth country—Philippines. An 18-hour flight seemed nothing compared to more than a decade of being away. The excitement to speak in Tagalog again, touch Filipino patients, and heal the people who cannot afford to pay private physicians motivated us to plan this medical mission for more than a year. The partnership with the local municipal health officer and the mayor made the collaboration easy. But no! The process of applying for temporary medical licensure, recruiting local physicians who would be available while we were there, and sending the medical supplies from the US was not pain-free and fast.
In the midst of the humid summer, we arrived on site, armed with our American way of training. Yet, we were not in America. We were ready to screen for cervical cancer. There was no liquid-based cytology. Not all beds had stirrups. The local health center used the conventional glass slides and hair spray as fixatives. We had to use a rolled towel to lift the pelvis up while the women’s legs were in frog-leg position. We used a flashlight to illuminate the pelvic area. We learned their way of doing it, which was their right way.
They were the expert and we were their partners. We were there as extra hands. In eight hours, with five physicians, we did pelvic examination and pap smear on 219 women. It felt like an assembly line with the community health workers doing the intake history-taking, then we did the speculum and pelvic examination, then another team of health workers doing the fixation, labelling, and packing.
It flowed very smoothly. Nobody complained. Patients waited for their turn with smiles on their face. One glass slide broke during the packing and the patient came back with no signs of disappointment. She eagerly went to the examination table since she already knew the drill.
Clearly, we were not the superhero in this mission. We were impressed that with very limited resources, how could they make this process worked so well. How community health workers who had elementary or high school diploma be an effective and efficient part of the health care team. They were empowered.
We concluded with a better understanding of ourselves and how we could mutually learn and support one another. The adaptability, resilience and community engagement during the medical mission in the Philippines shed more light to me. Health care collaboration was a meaningful and sustainable experience when resource-rich countries partnered horizontally with host countries. Letting them lead their right way, and we would follow along.
Note from the Editor: The December blog contains two important submissions on global family medicine and the factors that contribute to inequities in the field including but not limited to funding, climate change, geopolitical events, and more. Thank you to Barry Bacon, MD, Martha Sommers, MD, Bhargavi Chkuri, MD, and Meredith Milligan, MD
Dream School: How One Patient Encounter Can Change the Direction of Your Life
One patient encounter can change the direction of your life.
Our team, Gambella Medical Team Connections in Western Ethiopia and Anchor Health for South Sudan in South Sudan, dreams of creating a medical school to change health outcomes for the region. This long-term strategy will build up the region’s workforce with physicians and other local-to-the-area healthcare workers familiar with the area’s needs.
The challenges we face include:
Lack of livable wages. Doctors in South Sudan are employed by the government and receive $12 per month.
Lack of funding and support. Donor countries who had been sponsoring healthcare support in South Sudan have retracted their financial support.
Lack of access to quality medical care. There are five hospitals in the Gambella region serving a million people. These hospitals have one functioning x-ray machine and one functioning operating room.
Lack of physicians. There are 120 physicians in South Sudan serving a population of 12 million, a ratio of 1:100,000. In 2013, there were nine midwives and eight OB/GYNs identified in all of South Sudan. As a result, one in seven women die from childbirth complications. We witnessed a child dying in his parents’ arms while waiting to be seen by a physician at the central hospital.
Lack of access to medicines, equipment, and tools required to provide quality care.
Lack of tools. Nursing schools in Gambella don’t even have a blood pressure cuff and must teach their students without one.
Outsourcing. Medical care is outsourced at a cost of $200 million per year to other countries.
Conflict. There are 400,000 refugees in the Gambella region. Facility transfers must transport patients during times of conflict.
Many members of our team fled South Sudan and Gambella due to the conflict and violence. After arriving in the United States, they received an education and they returned to the region, bringing colleagues and US recruits with them with the goal of transforming healthcare in South Sudan and the Gambella region of Ethiopia. Thanks to presentations at the 2019 and 2021 AAFP Global Health Summit, we were able to grow our team and support network. The connections built by our team, along with their local knowledge led to Marshall University’s Family Medicine Global Health Division joining the effort; and the sharing of widespread contacts that contribute to our progress.
We’ve been offered a hospital in Juba to create a multi-specialty healthcare center and a base for medical education. Our vision is to invite US-based instructors and specialty teams to provide care for patients while teaching medical students and South Sudanese physicians. Additionally, we must address the policy fiascos that prevent healthcare professionals from receiving sustainable, livable income. For over five years, we’ve worked on our dream of developing an international medical school with campuses, and teaching sites in remote hospital and clinical settings in South Sudan and Western Ethiopia. We have the support of both leaders in South Sudan, the Gamebella regional government, and are audacious enough to believe we will accomplish our dream.
Globally, the world is asking more of family medicine. As teachers of family medicine, we are learning how to meet the needs in South Sudan and Gambella, and focusing on increasing opportunities to involve medical students, residents, and colleagues as we move forward.
Join us.
Barry Bacon, MD 250 S Main St Colville, WA 99114 Anchor Health for South Sudan Gambella Medical Team Connections baconbarry@juno.com
Martha Sommers, MD Assistant Professor Department of Family and Community Medicine Marshall University
Modernizing Global Women’s Health Curricula: Inclusivity, Intersectionality, and Climate Change
by Bhargavi Chekuri, MD, University of Colorado School of Medicine, Aurora, CO, and Meredith Milligan, MD, Dartmouth-Hitchcock Medical Center, Lebanon, NH
Gender inequality remains one of the most important drivers of disparities in health and well-being worldwide. To address these disparities, global women’s health research and curricula have been developed to better meet the unique health needs of women worldwide. While training programs often provide much needed focus on reproductive and obstetric care, infectious diseases, and cancer screening, significant blind spots remain.
First, gender continues to be categorized as binary in most of the research focused on global women’s health. As a result, teaching in this field fails to incorporate intersectionality, overlooking the physical and mental health needs of other sexual and gender minorities (SGMs). Additionally, teachers of global women’s health, and indeed medical educators more broadly, do not adequately integrate planetary health into their curricula. This is problematic because climate change is already worsening current global health disparities with well-documented gender-specific impacts, making it one of the most important, cross-cutting determinants of health in the 21st century. Research and teaching at the nexus of all three of these issues (global women’s health, health needs of other SGMs, and climate change) is even rarer, despite the fact that SGMs are particularly vulnerable due to compounding issues such as discrimination.
Gender-specific Impacts of Climate Change
Climate change harms human health by altering the quality and quantity of our air, water, food and weather. Increased temperatures and drought, poor air quality, more intense extreme weather events, and changing disease patterns all affect mortality and morbidity, resulting in injury, poor cardiovascular and respiratory outcomes, and worsening mental health worldwide. Globally, women and other SGMs face increased exposure to the consequences of climate change due to existing health disparities as well as differences in gender roles and responsibilities. When faced with these exposures, unequal resource distribution further limits the adaptive capacity and resilience of women and other SGMs. Women in low-income countries (LIC), for example, have disproportionate exposure to food insecurity because they are more likely to live in poverty and rely on subsistence farming to feed themselves and their families. When faced with lower crop yields, women are at higher risk for nutritional deficiencies, both because of increased reproductive demands (like menstruation and pregnancy), and because of underlying cultural norms that may prioritize feeding others. Similarly, gender-based social and cultural norms place responsibility for managing household water supply on women in LICs. As climate change strains freshwater resources globally, women spend more time and travel farther to locate, transport, and secure household water. Along the way, they can have increased exposure to heat, musculoskeletal injury, and face the threat of violence or abuse. Climate-related disasters like wildfires, storms, and flooding also have gendered health impacts. Women in low and middle-income countries are more likely to die from extreme weather or flooding events than their male counterparts because they are also more likely to be homebound, serving as caregivers, and unable to immediately escape climate-related disasters. Simultaneously, women have unequal access to disaster response services in the aftermath of such events, often losing access to essential sexual health and reproductive health services (SHRH) right when they need them the most.
SGMs are particularly socially vulnerable during disasters due to existing inequities as well as discriminatory disaster response policies. In the U.S., for example, LGBTQ+ people are more likely to live in poverty, experience unstable housing, and have chronic physical and mental health conditions, all leading to a higher risk of direct and indirect injury during extreme weather events. Additionally, disaster response policies in the U.S. do not explicitly prohibit discrimination based on sexual orientation or gender identity, or routinely recognize gender-diverse family structures, opening LGBTQ+ people to harm and separation when pursuing relief.
A Path Forward
Unfortunately, these are just a few of the many ways women and SGMs around the world are disproportionately impacted by the changing climate. Practitioners and teachers of global women’s health must be aware that current gaps in global health research limit our ability to fully understand and address gender-based health disparities worldwide. Integrating an intersectional and inclusive lens while defining, understanding, and teaching global women’s health is an important first step in addressing health disparities felt by women and other SGMs. Global women’s health practitioners must also use and teach a planetary health lens so they are better prepared to address contemporary health threats. Those leading community-based collaboration and bidirectional global women’s health partnerships must understand and teach concepts like gender-mainstreaming and climate action when developing projects aimed at improving women’s health. Lastly, global women’s health practitioners must understand and teach the importance of applying reproductive justice and human rights frameworks to climate action plans; this not only improves the adaptive capacity and resilience of women and other SGMs but also subsequently improves gender-based health disparities.
Definitions:
Sex refers to the biological characteristics that define humans such as female or male.
Gender refers to the socially constructed characteristics, norms, roles, and behaviors attributed to women, men, girls, boys, and non-binary people. Because gender is a social construct, ideas about gender vary across societies and time.
Gender equality refers to the equal rights, responsibilities, and opportunities of all genders.
LGBTQ+ is an acronym that collectively refers to individuals who are lesbian, gay, bisexual, transgender, or queer. The “Q” can also stand for questioning, referring to those who are still exploring their own sexuality and/or gender. The “+” represents those who are part of the community, but for whom LGBTQ does not accurately capture or reflect their identity.
Sexual and gender minorities (SGMs) refers more broadly to people whose biological sex, sexuality, gender identity and/or gender expression depart from majority norms. The term ‘sexual and gender minorities’ includes considerable diversity as well as a multiplicity of identities and behaviors, including, but not limited to, individuals who identify as LGBTQ+. The term ‘sexual and gender minorities’ is preferentially used in global health contexts because the term ‘LGBTQ+’ is derived from Western contexts which may not apply to many people in the world.
Intersectionality refers to a theoretical framework born out of the Black feminist movement which maintains that individual identities (such as race, class, gender, sexual orientation, immigration status, etc.) intersect to create experiences of inequality within society. Research using intersectionality methods is ideally built on a foundation of coalition-building with the aim of gaining a deep understanding of the diversity of lived experiences and the ways in which systems of oppression and privilege impact these varied experiences. Such research also maintains that emphasis on one identity over another fails to capture the true causes of disparity in the world.
Gender mainstreaming is defined by the UN as “the process of assessing the implications for women and men of any planned action, including legislation, policies, or programs, in all areas and at all levels. It is a strategy for making women’s as well as men’s concerns and experiences an integral dimension of the design, implementation, monitoring, and evaluation of policies and programs in all political, economic, and societal spheres so that women and men benefit equally, and inequality is not perpetuated. The ultimate goal is to achieve gender equality.”
Bhargavi Chekuri, MD, is Co-Director, Diploma in Climate Medicine, and Assistant Professor, Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO
Meredith Milligan, MD, is Family Physician and Leadership Preventive Medicine Resident, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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