Category Archives: Health Equity

Double Feature: A Spotlight on Global Health Education

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

References

(1)https://www.who.int/director-general/speeches/detail/the-rising-importance-of-family-medicine

Margaret Chan. (June 26, 2013). The rising importance of family medicine. Paper presented at the 2013 World Congress of the World Organization of Family Doctors, Retrieved from https://www.who.int/director-general/speeches/detail/the-rising-importance-of-family-medicine

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

Working for Health Equity –Together

By Lloyd Michener, MD

Family medicine groups have responded wonderfully to the COVID-19 pandemic, providing critical clinical services, and helping staff testing and vaccination sites. As COVID-19 underscored the depth of the disparities across our states and communities, family physicians have also taken on local and national leadership roles in health equity efforts, efforts to achieve health equity are now expanding rapidly, and the approaches and even the language used are changing as well.

As a particularly horrific example, a new report from the US Civil Rights Commission calls for equity in maternal health, noting that Black women in the United States are 3 to 4 times more likely to die from pregnancy-related complications than White women in the United States. The report calls for coordinated prenatal, maternity, delivery, and postpartum care that manages chronic illness and optimizes health, and points out the role that states can play in supporting equitable health, including Georgia, New Jersey, and North Carolina. Maternal health equity is an opportunity for family medicine, partnering with our health systems, our communities, and our states, to make a difference.

At the same time, academic health centers (AHCs) are increasingly engaged in health equity efforts, seeking to build and strengthen community partnerships for health. As David Skorton, CEO for the Association of American Medical Colleges, stated:

“the traditional tripartite mission of academic medicine — medical education, clinical care, and research — is no longer enough to achieve health justice for all. Today, collaborating with diverse communities deserves equal weight among academic medicine’s missions. This means going beyond “delivering care” to establishing and expanding ongoing, two-way community dialogues that push the envelope of what is possible in service to what is needed.

It means working with community-based organizations in true partnership to identify and address needs, and jointly develop, test, and implement solutions. This requires bringing medical care and public/population health concepts together and addressing upstream fundamental causes of health inequities.”

https://journals.lww.com/academicmedicine/pages/articleviewer.aspx?year=9000&issue=00000&article=96573&type=Abstract

This is a new challenge for many AHCs, and a place in which family medicine can make a much-appreciated difference. A private, research-intensive school headlined such an example:

In many ways, the COVID-19 pandemic forced positive changes in how medicine is practiced in communities and at academic medical centers, with family medicine departments working at the front lines to provide care and forge relationships with community partners, according to a Duke Health review.

https://corporate.dukehealth.org/news/pandemic-response-shows-path-improved-health-care-future?utm_source=newsletter&utm_medium=email&utm_content=The%20pandemic%20shows%20a%20path%20toward%20a%20better%20health%20care%20future&utm_campaign=dukedaily2021_09_20

As these partnerships grow, the language shifts. Family medicine is growing accustomed to the idea that we have a role in the ‘social determinants of health,” while community organizations may use a broader, more positive framing of the “vital conditions of health” which is inclusive of the intersections of health and safety, work, transportation, education, civic muscle, housing, and the environment. Family practices can have important roles in this larger effort, both as trusted sources of care and information, as one of the community hubs that link individuals and families to needed services, and as respected advocates for needed policy change so that all communities have the opportunity to thrive.

Guidance on how to partner and support community health equity is increasingly available, including, to cite just a few:

It is noteworthy that every one of these draws from diverse groups and sectors, as working effectively with community organizations towards health equity requires partnerships far beyond any one discipline, profession, or sector.

Within all this complexity and challenge, family medicine has a wonderful opportunity to serve as builders of bridges to and with our diverse communities, many of whose members come to us for care. By expanding our vision so that we are engaged with communities around their priorities and needs, we can help build on their strengths, add our own and those of our academic colleagues, to our shared goal of achieving health equity.

Fierce Women and New Stars

For a long time I thought I was lucky to have fierce women who walked beside me & now I see the real luck was that these fierce women stayed there until I learned how to be fierce myself. —Brian Andreas, Creator of Story People and Flying Edna

AndreaAnderson

Andrea Anderson MD
The GW School of Medicine and Health Sciences

These words hang on the wall of my office and were the inspiration of my remarks when I accepted the 2019 Advocate Award for my work in encouraging resident advocacy. As I reflect on my career thus far as an academic physician, it is clear that actively seeking opportunities and receiving excellent mentorship have been driving forces. It is not a secret that mentorship is important in any career path. It is crucial for us as Black and Brown medical educators.

I grew up as the daughter of an inner city public school teacher. Even now, some 20 years later, my mother’s influence is still evident when former students happily greet her around town and proudly show off their accomplishments. After high school, I was accepted into the combined BA/MD program at Brown University. Even at a large progressive school like Brown, I could count on one hand the numbers of Black and Brown faces who stood before our medical school class as faculty or deans. My school was not unique. Nationwide, the numbers of Underrepresented in Medicine (URM) Faculty in US medical schools remains well below 10% and has not kept pace with the increasing diversity among the student body or the society as a whole. One of those faces who significantly impacted me was Alicia Monroe MD, current provost of Baylor College of Medicine. She was one of the plenary session speakers at the last STFM Annual Spring Conference in Toronto. When she was our dean of Minority Students at Brown, my friends and I would go to her office to receive support, guidance, mentorship, or frankly just to see a face that looked like ours. Recently I was heartened to hear that among the reasons she was encouraged by her then department chair to pursue promotion early in her academic career was because of all the female junior faculty and women who looked up to her. I was definitely one of them. My experiences as a student leader at Brown solidified my passion for advocacy and imprinted me with the notion of my responsibility to speak for those who have no voice.  I was awarded the National Health Service Corps Scholarship and committed myself to a career in family medicine.

After Brown I trained at Harbor-UCLA and completed an academic medicine fellowship and chief resident year. I continued to raise my voice as an advocate for marginalized and immigrant populations. In Southern California I became the president of our Resident Union and collaborated with local labor unions to help fight cuts to the community health center safety net.  I began to see how I could combine my passion for social justice with my love of teaching and medical education. Rooted among hardworking new and first generation mainly Spanish speaking immigrants, I became firmly bilingual. One of my patients even called me an honorary Latina. This work became not just something I loved to do, rather, it was something I had to do.  After completing my fellowship, I came to Washington, DC to serve my 2-year NHSC service commitment.

Those original 2 years morphed into 15 years as I stayed far past my service commitment serving a largely immigrant population at a 25,000 patient FQHC in DC. I sought out leadership roles such as medical director, director of student and resident education, and director of family medicine. As core faculty for our teaching health center/GME residency, I was introduced to STFM and attended my first conference in 2015.  I applied for and was selected for the Quality Mentoring Program and the Emerging Leaders Fellowship. In DC I continue to be active in professionalism and assessment as the appointed chair of the DC Board of Medicine and as an item writer and reviewer for the NBME. As a local advocate I have had the privilege to testify on a variety of topics affecting marginized populations before audiences as diverse as the AAFP, the Association of Clinicians for the Underserved, DC government, and the Senate HELP Committee. I taught health literacy, advocacy, and health policy to the students who rotated at our center and to the residents in our THCGME residency. I am excited to continue my interests in advocacy and professionalism as a recent appointee to the Board of Trustees of the Family Medicine Education Consortium and to the Board of Directors of the American Board of Family Medicine.  During my time at Unity, I taught scores of students from the GW School of Medicine and Health Science, a DC target school without an FM presence. I served as a kind of de facto community family medicine clerkship director as FM experiences were few and far between for the students.  My work as an adjunct was recognized—I advocated for increased roles for community medicine faculty role and was accepted into the Master teacher Leadership Development Program at GW, named to medical school committees, chosen to direct the senior capstone course, and promoted to clinical associate professor. These professional opportunities were the result of hard work and dedication along with the influences of key mentors along the way. Recognizing the voids in my past student experiences motivated me to think of creative ways to combine my passion and interests with my career goals. My life was busy and full as I juggled my work with my roles as a mother of two young children, a wife, and a daughter.

Although I felt respected from my adjunct teaching position, I began to feel that I could have a bigger impact at a university level as a full-time faculty member. Years of student and faculty advocacy for FM at GW caught momentum and I was asked to join the leadership of a small new Division of Family Medicine. This switch necessitated that I get firmly on a full-time academic track. But on the other hand, I loved my FQHC patients, families who I had cared for for generations. I struggled with how to advocate for them, full of angst as I announced my decision to leave. Several cards and letters of gratitude poured in from my patients and friends.  However, one from a teenage patient I have cared for since she was in kindergarten left a permanent mark on my heart.  In her adolescent script she said:

Don’t worry about me, Dr Anderson, I will achieve my dreams. I appreciate you so much.  But I know it is time for you to move on, time to make new stars. Many students will appreciate your hard work so they can light up their dreams as well.”

So this year at commencement, I will walk in my academic regalia, this time with the other full-time faculty. When I hear those bagpipes I am again reminded how proud I am to be an African American woman in academic medicine. In the spirit of those who have mentored me along the way, I march proudly and cheer for my students. As URM faculty, our presence says that we are still here and you can be here too. We are contributing, shaping the scholarly discourse of primary care, medicine, and public health for years to come. I nod to everyone, but especially to all those grandmothers and parents and aunties and uncles of color who have sacrificed, sweated, and prayed so that their loved ones could achieve their dreams. That nod that says I see you, and I am standing up here for you. I think of my own grandmother, a proud, smart, and beautiful woman who missed out on her college and career dreams, so eventually I could realize mine. I think of my former immigrant patients and how it is my responsibility to speak up for them. I think of the theme song played as I accepted my STFM Advocate Award, “Girl on Fire” by Alicia Keys.  STFM is a place where we are reminded that as family medicine educators, we are all on fire to create, as my teen patient and Brian Andreas would agree, Fierce New Stars. Let’s keep our torches burning brightly to do just that.