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To "First Do No Harm," Students Value Locals As Community Experts - the Global Health Pathway to Discovery

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Anesthesia Training in Uganda

Dr Shin-e Lin, MD, anesthesia resident and Global Health Clinical Scholar, leads airway simulator session with first-year anesthesia residents in Uganda 
Photo: Gerald Dubowitz


By Mitzi Baker

As a resident in pediatrics at UCSF, Christopher Stewart, MD, first went to Vietnam in 2000 on a medical mission that turned out to be eye-opening, but not in a way he had expected. He realized that many of the services he and his colleagues were providing—such as distributing donated medicines and performing surgeries—were actually doing more harm than good. The projects and interventions that volunteers worked so hard to establish were unsustainable if they didn’t train locals in the field to carry on the work. “People like me returned to the United States thinking we did really good, heartwarming stuff,” says Stewart, who is a pediatric hospitalist at San Francisco General Hospital. “But I stayed behind and realized more and more that I needed to be honest about the real impact of our global health work.” Most of the problems seemed to result from not understanding the multifaceted context of the locale and from not comprehending what the people being helped really wanted. “There were echoes of colonial attitudes, even in those with the best of intentions,” he says.

Having participated in global health projects as a student, resident and faculty member, Stewart is now the director of the Global Health Pathway where he has the opportunity to reinforce to learners that they carefully consider how and what they can do to best help those with few resources.

Learners from a wide range of specialties are attracted to the Global Health Pathway. Students with a variety of interests have participated, as well as residents from the Departments of Psychiatry, Surgery, Pathology, Radiology, Pediatrics, ObGyn and Family Practice and others, as well as trainees from UCSF’s other professional schools. The commonality is that they are keyed into wanting to address disparities and equity issues in the world. “More than simply craving adventure, these learners are in touch with what made them want to be a doctor, to make a difference for people individually and for populations that aren’t getting the equitable care that could make lives better,” says Stewart.

The feeling of making a difference can be more obvious in international resource-scarce environments, he adds, as the domestic practice of medicine—the sub-specialization, the paperwork and the reliance on technology—often blunts the feeling of direct care and impact.

Creating A Sustainable Resource

The passion for global health leads Pathway learners along varied career paths. Some continue with their practices domestically but arrange to continually go back to a country or region, while others pursue an academic career by applying their own specialty (such as radiology or surgery) to the global health field. Other graduates focus on policy and leadership roles at organizations with a global health focus such as the WHO, USAID or the Centers for Disease Control and Prevention, or they found their own non-profit organizations.

Michael Lipnick, MD, who did Global Health Pathways projects both as a medical student and as an anesthesia resident, co-founded the nonprofit Global Partners in Anesthesia and Surgery (GPAS) in 2007 with the goal of finding ways to improve surgical and perioperative care in resource-poor settings such as Uganda. GPAS has additionally created a process by which Global Health Pathway learners can learn and contribute in a meaningful way to improving health care in Uganda.

Lipnick learned firsthand from his own Pathway experiences that simply showing up in a foreign country eager to contribute didn’t necessarily end up feeling like much of a contribution. “The impetus for us forming GPAS was to implement anesthesia and surgery projects that developed sustainable relationships between Ugandan researchers and clinicians with global health learners and faculty, rather than sending them over piecemeal without any communications or mechanism for continuity,” he says.

As a student, Lipnick did a six-week clinical rotation at Mulago Hospital in Kampala, Uganda, which provided the inspiration for him to continue returning to that site annually for the last eight years. As an anesthesia resident, Lipnick used the Global Health Pathway to continue some projects that he had already begun at Mulago Hospital, specifically to explore what lasting effects international surgery and anesthesia projects had on health care in Uganda.

Listening to the Local Community

The Pathways program allows learners protected time to pursue a project for one to three months. “Unfortunately in that amount of time it is often hard to get plugged into a productive project that has any kind of long-term impact,” says Lipnick.

To address that challenge, Lipnick and GPAS co-founder Gerald Dubowitz, MD, connect Pathway learners with projects that local Ugandans have identified as being useful to them. Lipnick, who is currently a clinical fellow in critical care, and Dubowitz, who is currently an associate professor in the department of anesthesia, personally mentor the learners who go to Mulago Hospital and other sites in Uganda, helping them integrate into ongoing projects or to develop their own. Most importantly, the mentors’ experiences facilitate a relationship between learners and the country’s culture —an invaluable resource for any global health project.

GPAS has substantially increased the numbers of anesthesiologists and surgeons trained in Uganda. The organization addresses everything about how surgery and anesthesia are delivered there, from how patients get to the hospital to the quality of care they get to how they are discharged. “It is a very good experience for students to learn how to evaluate the quality of care and to be part of a process of change,” says Dubowitz. Once learners collect data and pinpoint a specific problem, then they can find a fix for it. “The idea is to engage in sustainable projects and potentially have an opportunity to directly impact a very large population,” he says. “We don’t do a project that is just going to be a flash in the pan.”

In addition to being a model for effective global health work, GPAS represents an emerging mindset in the field—to expand beyond infectious disease as its focus. Surgical conditions account for nearly 11 percent of disease worldwide, and traffic-related injuries are expected to surpass all infectious diseases by 2030. “Surgical issues of many kinds are incredible burdens but people don’t really think of them when they think of global health,” says Stewart. “These folks at GPAS are pioneering putting surgery as a global health issue on the map.”

An Ethical and Guided Approach

GPAS is one example of a successfully planned channel for global health learners to make productive contributions while they are learning, which exemplifies the experience that Stewart aims for overall in the Global Health Pathway. To give Pathways learners the best chance of doing useful global health work, he imbues learners with a sense of the field’s history and the value of learning from previous mistakes, the field’s unique vocabulary, the additional challenges that international work poses, the significance of understanding a location’s culture, economics and politics, and most importantly, how to incorporate the ethics and principles of doing effective work.

“As doctors, we have this pledge to ‘first do no harm,’ and in many situations in the global health setting, people have gone in with best of intentions and done more harm than good,” says Stewart. “Most of all, we want to convey cultural humility,” he says. “Simply listening and responding to what people want allows learners to think about how to create a positive impact with their time and passion.”