GLOBAL HEALTH EDUCATION PROGRAMS
Guiding and Sustaining Leaders
To improve world health by mentoring a new generation of leaders, the UCLA Center for World Health provides clinical, research, and humanitarian education and training for medical students, residents, fellows, and faculty from UCLA and around the world. Programs at the UCLA campus and at clinical and research training sites in diverse international settings encourage learners to engage health challenges worldwide through a compassionate and humanistic lens. The Center’s Global Health Education Programs are led by Drs. Tom Coates, Lee Miller, Tanya Arora, Dan DeUgarte, Jorge Lazareff, and Traci Wells. For more information, please email Traci Wells at firstname.lastname@example.org.
Please visit our EXPLORE database for a comprehensive view of the global education and training programs conducted by faculty at the David Geffen School of Medicine and UCLA Health in collaboration with international partners.
Photo: Dr. Jorge Lazareff presents a course to students at Universidad Científica del Sur in Lima, Peru.
By Jorge Lazareff, MD, FAANS, Emeritus Professor of Neurosurgery; Director of Latin America Initiatives, UCLA Center for World Health
Although the largest number of patients globally live in low and middle-income countries, much of the world’s leading research and healthcare advances originate in high-income countries. This has created a unidirectional flow of information that hinders low and middle-income countries’ production of medical knowledge when compared to high-income countries.
Closing the Publication Gap
We recently surveyed medical literature, enquiring into the number of papers authored by physicians from Africa, Asia, and Latin America about the implementation of a preoperative surgical checklist (SCL). The SCL is a system recommended by the World Health Organization that improves safety in the operating room. Compliance to the SCL does not depend on any specific surgical equipment, and therefore it is as applicable in Boston as it is in Managua. The survey found that physicians from high-income countries have authored more than 800 papers on this subject, while their colleagues from low and middle-income countries produced a mere 79 articles.
Similar results can be found when looking at any other healthcare related subject, even for diseases that are not prevalent in high-income countries, such as malaria or Chagas.
A large volume of valuable observations by low and middle-income country healthcare workers is lost because of this phenomenon. There are countless clinical events that can apprise us of the many nuances of treatment alternatives, particularly in the face of scarce resources. For example, in high-income countries, children born with open spina bifida are operated on within 24 hours of birth. This is not the case in Guatemala, where there is only one hospital of referral. If there is a difference in outcome between countries, what can this tell us about spinal cord injury?
Another example and current clinical problem in Nicaragua is renal insufficiency among sugar cane workers. Why has this picked up now and not years ago and why is this not seen in Argentina’s cane workers? In essence, what questions about diseases can emerge when looked through the epistemological gaze of a local healthcare worker?
Our thesis is that by assisting health care workers form low and middle-income countries in the process of structuring clinical research, we can incite clinical study and revert the unidirectional flow of information.
While we acknowledge that language and rhetorical style are barriers to bidirectional communication, it is important to stress the colonial history that all low and middle-income countries share. This record of past governance by imperial power and present cultural dominance foments the idea that knowledge generated in low and middle-income countries is not as valuable as that coming from high-income countries.
Evidence-Based Medicine and the Philosophy of Science
In high-income countries, evidence-based medicine (EBM) is the preferred method of clinical discovery. EBM has many virtues, however falls short by relying too heavily on technology for giving accurate diagnoses. The social and economic reality in low and middle-income countries demands a broader range of flexibility and creativity in the medical process.
For that purpose, the principles of the philosophy of science can be instrumental in solving clinical puzzles. For example, Hempel did an excellent analysis of Semmelweis’ thought process when facing puerperal fever outbreaks. We need to perceive the surgeon in Matagalpa as a scientist who is well versed in the power of Modus Ponens or Hill’s Criteria of Causation. We must also be aware that those clinical observations are often different from that of a physician from a high-income country.
Tele-Education Program in Latin American Medical Schools
In 2014, we partnered with one medical school in Central America to conduct a live webinar series of lectures on clinical research, with the goal of assisting healthcare workers from low and middle-income countries in structuring their observations and developing a clinical research program. Each series totals eight hours of lecture, covering the following main topics: Reason in Diagnostic and Treatment, Inductive and Deductive Logic and its Fallacies and Causality, and Designing Hypothesis-Driven Clinical Research.
The course also illustrates the process of discovery, with narratives about the thought processes that lead to the etiology of duodenal ulcer, neural tube defects, and AIDS, among other examples. We aim at emphasizing the value of observation. We link the thought of Popper, Hempel, Quine, and Feyerabend to clinical investigation.
By February 2018, six medical schools have partnered with UCLA and three hundred fifty-six participants have completed the course. Encouraging results include the creation of a medical student-run research society, an online medical journal, and four papers, two of which have been accepted in PubMed journals and two that are in revision.
This program highlights the many ways through which Academic Institutions can collaborate with each other. For us at the Center for World Health, charity is vertical and solidarity is horizontal.
The Conrad N. Hilton Foundation has announced a $2.6 million grant to UCLA Center for World Health Director and Distinguished Professor of Medicine, Dr. Thomas J. Coates to expand implementation of the integrated early childhood development (ECD)/Option B+ model in Malawi. The model, which provides ECD training in concurrence with an Option B+ program to prevent mother-to-child transmission of HIV, seeks to improve caregiving skills of mothers living with HIV and to promote early stimulation and communication with infants exposed to HIV.
In 2015, UCLA, Partners in Hope (PIH) Medical Center in Malawi, and the University of Witwatersrand in South Africa joined with the Hilton Foundation on a two-year pilot program to assess the feasibility and acceptability, as well as initial outcomes, of supporting Option B+ mothers in Malawi. The program focused on Option B+ mothers in recognition of the fact that these mothers have numerous vulnerabilities in addition to their HIV infection. The pilot work further defined and documented these vulnerabilities, including lack of partner support, struggles with paying for transport and providing proper nutrition to their children, and community level stigma and discrimination. The focus on HIV-exposed infants was in line with studies suggesting an increased risk of developmental delays among HIV-exposed uninfected children. Additionally, like their mothers, HIV-exposed infants face increased vulnerability in nearly every aspect of life, particularly in the environment of extreme poverty that exists in rural Malawi.
From 2015-2017, the pilot worked with mother-infant pairs at two district hospital sites in Malawi- Kasungu and Nkhotakota. Mothers were enrolled in once per month ECD sessions for 10 months, timed to coincide with the women’s ART refill dates. From April to December 2016, 161 mother-infant pairs were enrolled in the program. 95 (59%) of pairs remained active in both ECD sessions and in their HIV care. Of the 47 (24%) infants classified with moderate developmental delays at baseline, 44 (94%) moved to normal development at follow-up. Home visits showed that over 90% of infants had appropriate stimulation and communication from caregivers outside of clinic settings. Exit interviews with the mothers indicated strong satisfaction with the program and a keen interest in continuing with ECD activities in their communities.
Under the new grant, PIH will expand access to ECD training in clinics at nine health centers and seven hospitals in Lilongwe District, and expand to additional facilities in the original two districts (Kasungu and Nkhotakota). Building upon PIH’s existing infrastructure, the project will make use of Expert Clients to support mothers and their infants. Expert Clients are HIV+ individuals who provide support to community members to support disclosure, retention, and prevention. Under the grant, an additional 80 Expert Clients and 20 Lead Expert Clients will be trained on ECD/Option B+ integration.
The project will also incorporate a cost-benefit analysis of the integrated ECD/Option B+ model and identify the most cost effective method to deliver ECD and Option B+ in a low resource, high HIV prevalence setting, such as Malawi. The cost data will be used in advocacy efforts with the government around the cost-benefit of adding ECD into standard health programs as part of the national strategy.
Other faculty involved in the project are Alan Schooley, MD, (Clinical Co-Director and Supervisor for Central Region, EQUIP Malawi Project), Kathryn Dovel, PhD (Associate Research Director, Partners in Hope), Linda Richter, PhD (Distinguished Professor and Director, DST-NRF Centre of Excellence in Human Development at University of the Witwatersrand), and Laurie Bruns (Senior Regional Africa Director, UCLA Center for World Health).
The Brenda Lucille Miller UCLA-South African Education Fund for Movement Disorders at the UCLA Center for World Health provides opportunities for junior South African doctors and scientists focusing on neurological diseases to come to UCLA to engage in postdoctoral studies for periods ranging from one month to one year.
The Fund was created to honor the memory of Brenda Lucille Miller, a South African who lived with multiple sclerosis. Neurological illnesses tend to be underdiagnosed and undertreated in South Africa, and take a tremendous toll on individuals and families.
The purpose of the Fund is to build capacity in the areas of prevention, diagnosis, treatment, and management of neurological diseases, such as multiple sclerosis, Parkinson’s disease, and Alzheimer’s disease. Such capacity will benefit not only South Africa but the entire continent, as South Africa can become a clinical leader in these diseases for the region. The Fund will contribute to the development of South Africa’s ability to discover, deliver, and disseminate novel strategies through helping its medical and scientific professionals to get exposure to research and treatment developments in the United States and to provide ongoing mentoring and support for these practitioners as they return to South Africa.
The Fund brings early career doctors or scientists—those having just completed their medical and/or doctoral studies and beginning their clinical, teaching, or scientific careers—to Los Angeles for periods of one month to one year to work with UCLA faculty to learn clinical diagnostic and treatment skills in surgical, hospital, and outpatient clinical settings, with the goal of applying their new knowledge and skills to improve the diagnosis, treatment, and management of neurological diseases in South Africa and improve the health and well-being of their fellow South Africans.
The Fund is merit-based and competitive, with awards granted based on applicants’ training, records of achievement, and potential to succeed. An impartial panel comprised of UCLA and South African scientists, physicians, and professionals select finalists who go through an interview process to determine the awardees.