Friday, July 4, 2014

Global Health Credentialing

Yale medical diploma awarded Asaph Leavitt Bissell, Class of 1815

There is a trend in the global health literature calling for an authority to credential those who undertake medical humanitarian missions in low-income countries (LICs). The argument is that there is no oversight as to the medical or cultural competencies of these providers, and that harm ensues from well-intentioned but incompetent individuals.

Of course, patients in LICs deserve the same standard of care as those in high-income countries (HICs), accepting the different infrastructure, equipment, drugs etc. However, I feel that there are several arguments against a global credentialing hegemony.

In the US, licensed physicians can legally perform any medical procedure no matter their training. Hospitals require credentialing, but a physician can set up a private clinic and practice plastic surgery despite having trained as an ENT doctor. How can we insist on higher standards for those giving their time and skills to help those overseas?

Although there are anecdotes of incompetent visiting practitioners practicing sub-standard medicine in LICs, these incidents are rare. Conversely, incidents of malpractice are relatively common in the US despite our rigorous licensure process. More harm is perpetrated by well-funded, well-publicized organizations without a coherent perspective on global healthinternational development, or ethics

Medical volunteers are usually self-financed, and take time away from families and jobs. To add bureaucratic requirements for further training, examinations and paperwork would add further financial burden to volunteers and/or their organizations, and undoubtedly dissuade many from engaging.

In these financially strained times, charitable donations are increasingly limited. Endowing an overarching organization with standards-setting power is inviting manipulation of the global health agenda to one party’s financial advantage or philosophy. Patients gain much from a diversity of groups offering a broad range of services and philosophies.

How could such a credentialing institution actually prevent an individual or organization from travelling and treating patients? It is paternalistic to imagine that HICs need to protect the citizens of LICs. The governments of LICs are best placed to institute appropriate restrictions on an organization or individual’s scope of practice. For example, The Republic of Ghana requires visiting medical practitioners to obtain a Ghana medical license before they can participate in medical care - a perfectly reasonable and achievable standard, set by the nation and citizens concerned.

I believe a more reasonable alternative to a credentialing agency is an extension of the system currently practiced by many of the more successful humanitarian groups. Such organizations use an in-house credentialing process that mirrors that of an American medical institution. This prevents those few cases of ‘cowboy’ surgeons, and protects the organization from accusations of malpractice. I would suggest that these organizations could share credentialing information. If they agree to a credentialing standard, then once a practitioner is credentialed with, for example IVUMed they could work with ReSurge without further paperwork. Such a cross-credentialing service would encourage new volunteers to enter into this work with a well-established, philosophically coherent endeavor, and not the inexperienced groups that generate such bad press.

Sunday, May 25, 2014

Mountains Beyond Mountains

Despite being involved in global health for over a decade, I have only just read "Mountains Beyond Mountains" by Tracy Kidder. I had seen some criticisms of Dr. Paul Farmer and his model, and I think I expected the book to be a glossy overview of Partners in Health (PIH) and their good works. I was pleasantly surprised that it went into much more detail about Dr. Farmer's philosophy and development of the PIH approach to "curing the world" (perhaps explained by his interesting childhood).

Here is the thing that struck me about Dr. Farmer's work and the PIH model (this may be old hat to everyone else, but it was a bit of an epiphany for me). 'Public health' endeavors address community-level issues, and in this indirect way benefit individuals. Dr. Farmer's model attacks problems from the opposite direction - find the best way to treat individuals and that will benefit the community. For example, PIH's success in developing an effective approach to treating MDR TB in low-resource settings sprang from the desire to treat one or two individuals. This approach is now benefitting thousands through community-based programs in Europe, South America and Africa. It seems that Dr. Farmer is what Professor Easterly would describe as a 'searcher' rather than a 'planner'.

Overall, I enjoyed this book. Dr. Farmer is clearly a dedicated, charismatic and laudable character. While his projects may have deficiencies, some have been successful in situations where others have failed. In the diverse and chaotic field of global health, it is worth paying attention to one who has had success in the "long defeat".

Sunday, February 16, 2014


I co-direct the "Public Health and Surgery" course here at the University of Utah. This week in class we were discussing 'failure'. We heard from colleagues who had experienced program collapse, we watched David Damberger's talk on "Learning From Failure", and we had a nice chat about how and why projects 'fail'.
As I was listening to my venerable colleagues talk of adaptations made to ongoing programs in light of failed predictions, it struck me that the word 'failure' is often an inaccurate one in the global health / development paradigm - I even tweeted about it.
No successful global heath project has functioned perfectly out of the gate. Whether you look at smallpox eradication, vitamin-A administration in Nepal, or trachoma therapy in Northern Africa, all required modification and adaptation as initial expectations proved inaccurate, the program developed, and circumstances changed. Alanna Sheikh wrote a very nice post on this very subject - "When a program doesn't work".
There is, of course, much that could be discussed regarding when one should admit defeat with a particular endeavor. Erroneous premises, intransigent administrations or uncooperative donors can all doom a project. If and when to throw in the towel is, to misquote Dr. King, the "most persistent and urgent question".
I completely support the increasing culture of transparency around 'failure' for all the usual reasons (e.g. don't reinvent the wheel that doesn't roll, clarify to donors that this work is hard and complex, solicit help from initially uninvolved experts). However, I think we need a different word for the times when things don't go as we desire.

Until we walk away, it's not failure.

September 3 1967 - the day Sweden switched from driving on the left to driving on the right.

Monday, January 27, 2014

Talking to people

I am honored to have been asked to speak at UT Southwestern's 3rd Annual Global Health Symposium on February 8&9 2014.
As you can see, the topic is "Transformative Global Health: Impact and Accountability", which will make for a wide-ranging and engaging couple of days. For example, I'm going to be talking about the role of medical education in transforming global health i.e. inter- and intra- institutions, professions and regions.

I just finished reading "Pharmacy on a Bicycle", one of the authors of which (Dr. Eric Bing) is also speaking at the conference - very interested in chatting with him.

All in all, should be an illuminating and fun weekend - see you there?

UPDATE: This conference was indeed engaging with many learned speakers and some great work being done all over the world - I would heartily recommend attending next year if you can swing it. The UTSW Medical Center News wrote a very nice piece on my talk.

Sunday, June 9, 2013

Website returns.

After a ridiculously long time, we have managed to get our website up and running.

Hopefully this will give folks an idea of what our group does, and perhaps how we can help with their endeavors.

We are also in the process of uploading stripped-down versions of our refresher course lectures so they can be downloaded and used as educational resources in their own right.

Monday, September 24, 2012

Wednesday, May 23, 2012

Tweets from "Updates in Anesthesia" course.

We had a very successful "Annual Updates in Anesthesia" course (our 9th) in Kumasi, Ghana. The organizers (as always) did a superb job, and the 250+ attendees were engaged, enthusiastic and stimulating.

Below are some tweet highlights from the course: