Colonization and decolonization of global health: which way forward?

Despite taking on several forms throughout history such as colonial medicine, tropical medicine, and international health, the field of global health continues to uphold colonialist structures. History demonstrates that acts of colonialism inevitably lead to negative health outcomes. Colonial powers promoted medical advancements when diseases affected their own people, and only did so for locals when in the colonies' best interests. Numerous medical advancements in the United States also relied on the exploitation of vulnerable populations. This history is critical in evaluating the actions of the United States as a proclaimed leader in global health. A significant barrier to progress in the field of global health is that most leaders and leading institutions are located in high-income countries, thereby defining the global standard. This standard fails to meet the needs of most of the world. In times of crisis, such as the COVID-19 pandemic, colonial mentalities may be more evident. In fact, global health partnerships themselves are often ingrained in colonialism and may be counterproductive. Strategies for change have been called into question by the recent Black Lives Matter movement, particularly in evaluating the role that less privileged communities should have in their own fate. Globally, we can commit to evaluating our own biases and learning from one another.

Transforming medical education in Liberia through an international community of inquiry.

A critical component of building capacity in Liberia's physician workforce involves strengthening the country's only medical school, A.M. Dogliotti School of Medicine. Beginning in 2015, senior health sector stakeholders in Liberia invited faculty and staff from U.S. academic institutions and non-governmental organizations to partner with them on improving undergraduate medical education in Liberia. Over the subsequent six years, the members of this partnership came together through an iterative, mutual-learning process and created what William Torbert et al describe as a "community of inquiry," in which practitioners and researchers pair action and inquiry toward evidence-informed practice and organizational transformation. Incorporating faculty, practitioners, and students from Liberia and the U.S., the community of inquiry consistently focused on following the vision, goals, and priorities of leadership in Liberia, irrespective of funding source or institutional affiliation. The work of the community of inquiry has incorporated multiple mixed methods assessments, stakeholder discussions, strategic planning, and collaborative self-reflection, resulting in transformation of medical education in Liberia. We suggest that the community of inquiry approach reported here can serve as a model for others seeking to form sustainable global health partnerships focused on organizational transformation.

How Sanctions Have Impacted Iranian Healthcare Sector: A Brief Review.

Many studies have shown the crippling effects of sanctions on the healthcare sector of different countries, including Iran. Long-standing sanctions against Iran escalated recently and severely limited commercial activities with Iran. The devastating consequences of these embargoes have affected all aspects of health care delivery in Iran, limiting the availability of critical medicines and medical devices, and negatively impacting primary health care, treatment of complex diseases including cancer, medical tourism, and medical education and research. The present novel coronavirus disease 2019 (COVID-19) pandemic has uncovered this long-standing crisis in the Iranian health care sector. In this communication, we briefly discuss selected aspects of these sanctions and their impact on the health care system and people of Iran during this critical time.

Challenges in the Recognition and Management of Acute Kidney Injury by Hospitals in Resource-Limited Settings.

INTRODUCTION: Acute kidney injury (AKI) is prevalent in low- and middle-income countries (LMIC) and is associated with significant morbidity and mortality, particularly among hospitalized patients. Successful strategies for the prevention and management of AKI in these countries are dependent on the capacity of primary care centers to provide optimal initial management of patients at risk for this disorder. METHODS: From December 2018 to February 2019, using mixed methods, we assessed hospital capacity and the knowledge of clinicians relevant to the prevention, diagnosis, and management of AKI in Rwanda. A checklist based on Kidney Disease: Improving Global Outcomes (KDIGO) guidelines and clinical vignette-based assessment tool were used to assess hospital capacity and provider knowledge base, respectively. Data were analyzed using stata 13 with findings reported as simple frequencies or means with standard deviation. Multivariate analysis was used to assess factors associated with a higher knowledge score among clinicians. RESULTS: Ten hospitals and 193 health care providers from sites throughout Rwanda participated in the survey. Surveyed hospitals were equipped with basic general medical equipment but were deficient in diagnostic tools and medical supplies that would allow the diagnosis and nondialytic management of AKI. Although 20% of the hospitals could offer hemodialysis services, peritoneal dialysis services were nonexistent. With regard to knowledge base, the health care providers demonstrated significant deficiencies in the diagnosis and management of AKI. The mean knowledge score for all health providers was 6.3 (±1.5) of a maximum of 11, with a mean (±SD) score for doctors, nurses, and midwives of 6.3 ± 2.05, 6.4 ± 1.3, and 6.08 ± 1.2, respectively. On multivariate analysis, the length of clinical experience and age of the respondents were significantly associated with participants' knowledge score. CONCLUSION: This study documents significant barriers to providing optimal management of AKI in primary health care settings in Rwanda, a resource-limited setting. These include lack of specialized medical personnel, significant knowledge gaps among primary health care providers, suboptimal diagnostic capacity, and limited treatment options for detection and management of AKI.

Trends of admissions and case fatality rates among medical in-patients at a tertiary hospital in Uganda; A four-year retrospective study.

BACKGROUND: Sub-Saharan Africa suffers from a dual burden of infectious and non-communicable diseases. There is limited data on causes and trends of admission and death among patients on the medical wards. Understanding the major drivers of morbidity and mortality would help inform health systems improvements. We determined the causes and trends of admission and mortality among patients admitted to Mulago Hospital, Kampala, Uganda. METHODS AND RESULTS: The medical record data base of patients admitted to Mulago Hospital adult medical wards from January 2011 to December 2014 were queried. A detailed history, physical examination and investigations were completed to confirm the diagnosis and identify comorbidities. Any histopathologic diagnoses were made by hematoxylin and eosin tissue staining. We identified the 10 commonest causes of hospitalization, and used Poisson regression to generate annual percentage change to describe the trends in causes of hospitalization. Survival was calculated from the date of admission to the date of death or date of discharge. Cox survival analysis was used to identify factors associate with in-hospital mortality. We used a statistical significance level of p<0.05. A total of 50,624 patients were hospitalized with a median age of 38 (range 13-122) years and 51.7% females. Majority of patients (72%) had an NCD condition as the primary reason for admission. Specific leading causes of morbidity were HIV/AIDS in 30% patients, hypertension in 14%, tuberculosis (TB) in 12%), non-TB pneumonia in11%) and heart failure in 9.3%. There was decline in the proportion of hospitalization due to malaria, TB and pneumonia with an annual percentage change (apc) of -20% to -6% (all p<0.03) with an increase in proportions of admissions due to chronic kidney disease, hypertension, stroke and cancer, with apc 13.4% to 24%(p<0.001). Overall, 8,637(17.1%) died during hospitalization with the highest case fatality rates from non-TB pneumonia (28.8%), TB (27.1%), stroke (26.8%), cancer (26.1%) and HIV/AIDS (25%). HIV-status, age above 50yrs and being male were associated with increased risk of death among patients with infections. CONCLUSION: Admissions and case fatality rates for both infectious and non-infectious diseases were high, with declining trends in infectious diseases and a rising trend in NCDs. Health care systems in sub-Saharan region need to prepare to deal with dual burden of disease.

Developing medical education capacity in Russia: twenty years of experience.

BACKGROUND: The partnership between Yale University (USA) and Kazan State Medical University (KSMU, Russia) was established in 1996 and transitioned to Western Connecticut Health Network (WCHN)/University of Vermont Robert Larner, M.D. College of Medicine (USA) in 2012 with the goal of modernizing medical education at KSMU primarily through introduction of the American medical education structure, role modeling, and educational capacity building. It was centered on the formation of a select group of Russian junior faculty members familiar with American medical education who would then initiate a gradual change in medical education at KSMU. Here we describe the 20 year partnership, rooted in local capacity building, through which a sustainable, mutually rewarding international collaboration was established. In addition, we evaluate the program's outcomes and impact on medical education at Kazan State Medical University, and assess its influence on Russian program participants. METHODS: Senior residents and faculty were sent to KSMU to conduct teaching sessions with local faculty and trainees. Their responsibilities included familiarizing Russian colleagues with specific topics in clinical medicine, importing knowledge about the basics of teaching, clinical epidemiology and evidence based medicine, and creating, in consistency with the American model, a "Clinical Teaching Team Structure" that integrates patient care with clinical education. Furthermore, 44 of selected KSMU members, including 13 junior faculty (29.5%), 14 clinical PhD students (31.8%), 12 interns/residents (27.3%), and five medical students (11.4%), were trained at Yale/WCHN or one of their major affiliated community hospitals for a period of 1 to 12 months for a total of 844 participant-weeks of training. RESULTS: Thirty (68.2%) individuals who were trained in the U.S. are currently working in Kazan primarily as faculty at KSMU. Among them, three trainees (10%) have become heads of their department, eight (26.7%) hold senior faculty positions, and two (6.7%) have clinical and educational administrative leadership positions. Two major clinical departments have adopted the "Clinical Teaching Team Structure." As a result of the collaboration, three teaching courses - Evidence-Based Medicine, Tropical Medicine, and HIV/AIDS Medicine - have been designed and incorporated into the curriculum. CONCLUSION: This partnership has been instrumental in introducing the American medical education model and expanding the medical knowledge of faculty, residents, and students of KSMU on infectious diseases, HIV/AIDS, tropical medicine, renal diseases, and global health topics. Capacity building through the Yale/WCHN-KSMU exchange program has greatly contributed to the quality of medical education at Kazan State Medical University.

Implementation of Patient-Centered Education for Chronic-Disease Management in Uganda: An Effectiveness Study.

BACKGROUND: The majority of non-communicable disease related deaths occur in low- and middle-income countries. Patient-centered care is an essential component of chronic disease management in high income settings. OBJECTIVE: To examine feasibility of implementation of a validated patient-centered education tool among patients with heart failure in Uganda. DESIGN: Mixed-methods, prospective cohort. SETTINGS: A private and public cardiology clinic in Mulago National Referral and Teaching Hospital, Kampala, Uganda. PARTICIPANTS: Adults with a primary diagnosis of heart failure. INTERVENTIONS: PocketDoktor Educational Booklets with patient-centered health education. MAIN MEASURES: The primary outcomes were the change in Patient Activation Measure (PAM-13), as well as the acceptability of the PocketDoktor intervention, and feasibility of implementing patient-centered education in outpatient clinical settings. Secondary outcomes included the change in satisfaction with overall clinical care and doctor-patient communication. KEY RESULTS: A total of 105 participants were enrolled at two different clinics: the Mulago Outpatient Department (public) and the Uganda Heart Institute (private). 93 participants completed follow up at 3 months and were included in analysis. The primary analysis showed improved patient activation measure scores regarding disease-specific knowledge, treatment options and prevention of exacerbations among both groups (mean change 0.94 [SD = 1.01], 1.02 [SD = 1.15], and 0.92 [SD = 0.89] among private paying patients and 1.98 [SD = 0.98], 1.93 [SD = 1.02], and 1.45 [SD = 1.02] among public paying patients, p<0.001 for all values) after exposure to the intervention; this effect was significantly larger among indigent patients. Participants reported that materials were easy to read, that they had improved knowledge of disease, and stated improved communication with physicians. CONCLUSIONS: Patient-centered medical education can improve confidence in self-management as well as satisfaction with doctor-patient communication and overall care in Uganda. Our results show that printed booklets are locally appropriate, highly acceptable and feasible to implement in an LMIC outpatient setting across socioeconomic groups.

Medical Education Capacity-Building Partnerships for Health Care Systems Development.

Health care workforce development is a key pillar of global health systems strengthening that requires investment in health care worker training institutions. This can be achieved by developing partnerships between training institutions in resource-limited and resource-rich areas and leveraging the unique expertise and opportunities both have to offer. To realize their full potential, however, these relationships must be equitable. In this article, we use a previously described global health ethics framework and our ten-year experience with the Makerere University-Yale University (MUYU) Collaboration to provide an example of an equity-focused global health education partnership.

Adipsic hypernatremic myopathy.

Chronic hypernatremia due to adipsia is very rare and occasionally presents with muscle weakness and rhabdomyolysis. We report a patient with chronic hypernatremia without thirst sensation who presented with muscle weakness and was treated successfully with prescribed water intake.

Rational fluid therapy for sepsis and septic shock; what do recent studies tell us?

Sepsis and septic shock persist as major healthcare challenge, with high morbidity and mortality. Fluid management is a large part of the treatment in patients with these disorders. Fluid therapy has been an important component of the care of patients for the past century. However, recently well-designed studies have been published focusing on the impact of the type and amount of fluids on important clinical outcomes. This review summarizes all the relevant recent studies and attempts to develop a rational approach to the initial fluid management of patients with suspected sepsis.

The effect of a bidirectional exchange on faculty and institutional development in a global health collaboration.

PURPOSE: The MUYU Collaboration is a partnership between Mulago Hospital-Makerere University College of Health Sciences (M-MakCHS), in Kampala, Uganda, and the Yale University School of Medicine. The program allows Ugandan junior faculty to receive up to 1 year of subspecialty training within the Yale hospital system. The authors performed a qualitative study to assess the effects of this program on participants, as well as on M-MakCHS as an institution. METHODS: Data was collected via semi-structured interviews with exchange participants. Eight participants (67% of those eligible as of 4/2012) completed interviews. Study authors performed data analysis using standard qualitative data analysis techniques. RESULTS: Analysis revealed themes addressing the benefits, difficulties, and opportunities for improvement of the program. Interviewees described the main benefit of the program as its effect on their fund of knowledge. Participants also described positive effects on their clinical practice and on medical education at M-MakCHS. Most respondents cited financial issues as the primary difficulty of participation. Post-participation difficulties included resource limitations and confronting longstanding institutional and cultural habits. Suggestions for programmatic improvement included expansion of the program, ensuring appropriate management of pre-departure expectations, and refinement of program mentoring structures. Participants also voiced interest in expanding post-exchange programming to ensure both the use of and the maintenance of new capacity. CONCLUSIONS: The MUYU Collaboration has benefitted both program participants and M-MakCHS, though these benefits remain difficult to quantify. This study supports the assertion that resource-poor to resource-rich exchanges have the potential to provide significant benefits to the resource-poor partner.

Approach to the diagnosis and treatment of hyponatremia in pregnancy.

Hyponatremia is the most commonly encountered electrolyte abnormality. Severe hyponatremia in pregnancy poses diagnostic and therapeutic challenges. Pregnancy involves changes in physiology that affect water and sodium homeostasis. Knowledge of these complex physiologic alterations during pregnancy is critical to managing dysnatremias in pregnancy. This teaching case describes a woman with chronic hyponatremia who presented during pregnancy with worsening hyponatremia. She had an activating vasopressin receptor mutation, which was passed on to her child, and her diagnostic workup is described.

Use of anion gap in the evaluation of a patient with metabolic acidosis.

High anion gap (AG) metabolic acidosis, a common laboratory abnormality encountered in clinical practice, frequently is due to accumulation of organic acids such as lactic acid, keto acids, alcohol metabolites, and reduced kidney function. The cause of high AG metabolic acidosis often is established easily using historical and simple laboratory data. Despite this, several challenges in the diagnosis and management of high AG metabolic acidosis remain, including quantifying the increase in AG, understanding the relationship between changes in AG and serum bicarbonate level, and identifying the cause of high AG metabolic acidosis when common causes are ruled out. The present case was selected to highlight the importance of the correction of AG for serum albumin level, the use of actual baseline AG rather than mean normal AG, the relationship between changes in serum bicarbonate level and AG, and a systematic diagnostic approach to uncommon causes of high AG metabolic acidosis, such as 5-oxoproline acidosis (pyroglutamic acidosis).

Djenkolism: case report and literature review.

Djenkolism is an uncommon but important cause of acute kidney injury. It sporadically occurs after an ingestion of the djenkol bean (Archidendron pauciflorum), which is native to Southeast Asia. The clinical features defining djenkolism include: spasmodic suprapubic and/or flank pain; urinary obstruction; and acute kidney injury. The precise pathogenesis of acute kidney injury following djenkol ingestion remains unknown. However, it is proposed that an interaction between the characteristics of the ingested beans and the host factors causes hypersaturation of djenkolic acid crystals within the urinary system, resulting in subsequent obstructive nephropathy with sludge, stones, or possible spasms. We report a case of djenkolism from our rural clinic in Borneo, Indonesia. Our systematic literature review identified 96 reported cases of djenkolism. The majority of patients recovered with hydration, bicarbonate therapy, and pain medication. Three patients required surgical intervention; one patient required ureteral stenting for the obstructing djenkolic acid stones. Four of the 96 reported patients died from acute kidney failure. We stress the importance of awareness of djenkolism to guide medical practitioners in the treatment of this rare disease in resource-poor areas in Southeast Asia.

Attending rounds: patient with hypokalemia and metabolic acidosis.

Hypokalemic paralysis represents a medical emergency requiring both rapid diagnosis and treatment. In this Attending Rounds a patient with hypokalemia and metabolic acidosis is presented to emphasize the role of routine laboratory studies in the assessment of such patients so that a correct diagnosis can be made and appropriate treatment can be initiated promptly.

Short-term global health research projects by US medical students: ethical challenges for partnerships.

Recent interest in global health among medical students has grown drastically, and many students now spend time abroad conducting short-term research projects in low-resource settings. These short-term stints in developing countries present important ethical challenges to US-based students and their medical schools as well as the institutions that host such students abroad. This paper outlines some of these ethical issues and puts forth recommendations for ethically mindful short-term student research.