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Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 1-3

What's new in Academic International Medicine? Local advocacy for local problems: Involving the stakeholders in the involved citizen project

Department of Anesthesiology, Division of Critical Care, The Ohio State University College of Medicine, Columbus, Ohio, USA

Date of Submission05-Mar-2020
Date of Acceptance11-Mar-2020
Date of Web Publication27-Mar-2020

Correspondence Address:
Dr. Thomas J Papadimos
Department of Anesthesiology, Division of Critical Care, The Ohio State University College of Medicine, Columbus, Ohio
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_14_20

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How to cite this article:
Gray C, Papadimos TJ. What's new in Academic International Medicine? Local advocacy for local problems: Involving the stakeholders in the involved citizen project. Int J Acad Med 2020;6:1-3

How to cite this URL:
Gray C, Papadimos TJ. What's new in Academic International Medicine? Local advocacy for local problems: Involving the stakeholders in the involved citizen project. Int J Acad Med [serial online] 2020 [cited 2022 Jan 25];6:1-3. Available from: https://www.ijam-web.org/text.asp?2020/6/1/1/281451

Underserved and remote areas, especially in low- and middle-income countries (LMICs), do not have the economic strength or medical expertise to provide good prehospital care. Many locales do not have anything more than local word of mouth to provide effective interventions or patient delivery to a source of care. This unmet need cannot be met by a traditional health sector in LMICs. Using local citizens, their skills, and popular knowledge can be a source of remarkable and effective support.[1]

In this issue, De Wulf et al. present their development and implementation of aFirst Responder Program in Rural Haiti: The Involved Citizen Project.[2] LMICs bear much of the burden when it comes to injuries;[3] they cannot afford the cost of equipment and its upkeep, they are mired in poor infrastructure, they have a dearth of trained personnel, and many times, there is little political support for any needed efforts or improvements.

Haiti is a country with poor prehospital care and few properly trained medical personnel. So how does a country without resources overcome such difficulties? We found the authors' presentation of task shifting very interesting. Although this term, or action, was not invented by the authors, this concept of transferring skills from highly trained individuals to the local citizenry was clever and practical,[4] especially when the primary target of education is a professional driver (truck, taxi, etc.). The authors have correctly understood the need to combine urgent/emergent first responder skills with a person who could also deliver the patient to safe medical care. The training of skilled people movers in becoming the de facto providers of initial emergency care, in addition to the transportation arm of urgent/emergent care, is a praiseworthy effort.

The authors must be congratulated on using and consulting the local populace and their leaders in this effort. Thoughtful community engagement is something that all members of medical society should carefully consider, particularly in these times of Ebola Virus (EBV) and Covid-19.[5],[6] Some of the failures stemming from the EBV outbreak of 2014 involved a lack of local community consultation, engagement, and consent.[7],[8] In the current Covid-19 outbreak, there was not only a lack of local community involvement but also willful ignorance of leadership.[9] The successes demonstrated in the authors' efforts in Haiti are a consequence of their familiarity with, and engagement of, the community.

Curriculum development is a difficult task under the best of circumstances, but designing an educational program where the proper educational level of the populace is lacking, and there is inadequate equipment available to that populace, is very challenging. The curriculum that was developed by emergency medicine specialists with previous clinical experience in Haiti, in consultation with local practicing physicians, using an iterative-modified Delphi technique seemed to be both efficient and effective.

Programmatically, the community-based provision of prehospital emergency care must be effective, efficient, reproducible, and sustainable. The concept of training-the-trainer has been around for some time,[10] and the authors' use of this training method was especially useful in Northern Haiti. Considering the economic and public health circumstances of the region, a train-the-trainer programmatic format helps to optimize an already limited personnel base. The train-the-trainer methodology also allows for knowledge and skill set propagation.

In addition, such a program should be easy to replicate, and ultimately, it is this element of reproducibility that leads to sustainability.

It was of interest that among the trainees who reported using their skills, the trainees specifically mentioned using splinting skills, airway, breathing, and circulations (ABCs), self-protection, scene safety, and bleeding control while the importance of ABCs has been pounded into the public's mind throughout the world, bleeding control, especially the use of tourniquets, has not. High-income countries seem to be only recently grafting onto the concept of using tourniquets. These two specific skills, management of ABCs and bleeding control, we find to be of special importance in regard to the saving of lives in a rural, under-resourced area. Training-the-trainer, task shifting, using persons who are professional or trained drivers, allowing local input, and local adaptation in regard to a community program of this type are the cornerstones of success in implementing this kind of model. The authors have made the poignant observation that task shifting is the key concept here, but as they point out, it is a double-edged sword. While important in its implementation, there is cause for concern in the delivery of substandard care. Oversight of the process is of the utmost concern because literacy, foundational knowledge, and comfort with learning and teaching are paramount to the program's continued success.

Accordingly, there must be continuous reviews and reinforcement of care standards, procedures, and concepts. In the end, there will be limits on task shifting, and if not limits, then a careful observation of the program. Such oversight requires sustainable program supervision. By this, we mean that dedicated professionals in Haiti (possibly with outside advice) must closely follow the training and task-shifting aspects of this effort. Furthermore, there must be a way to quantify the results over the long term.

While similar models involving task shifting for the provision of emergency care have been described, the authors essentially present an inaugural program. As the program becomes more established and demonstrates sustainability, outcomes will need to be reported. In the 1-year follow-up survey, only 54% of participants felt they had mastered all concepts, with 50% of participants stating they felt that they had mastered all physical skills. While an observational study is probably the only practical and ethical methodology to use in this economic and public health situation, the results (outcomes) must be scrutinized to confirm the participants' mastery of emergency care concepts and physical skills and to ensure acceptable standards of care are met.

At the same time, local leaders and providers of healthcare must be ready for attrition from the ranks of those who have been trained to provide this much needed care. Even with the conscientious, culturally competent engagement of the community, there remain barriers to sustainability. The authors report a significant time requirement on behalf of the community participants, for both their initial education and subsequent teaching of additional community providers. The time commitment, in addition to a lack of financial incentive, may present a genuine impediment to recruitment, especially in LIMCs, where individual economic resources are limited. Given these hurdles, there will be a need for continued recruitment of personnel and a regular schedule of updates and review of skills.

The importance of this program is obvious. Sometimes, LIMCs cannot get outside aid, so homegrown programs are necessary for a society's well-being, but this can have negative consequences. As the authors have noted, “external aid has had unintended negative consequences for Haiti's health system, including siphoning resources and patients away from government hospitals.” While the authors correctly admit the generalizability of this program may not be certain, but as mentioned above, self-sufficient or self-supporting community health models can be very important in Public Health Emergencies of International Concern (PHEICS) in that an LMIC may have to support its populace until more aid arrives (and of course that help must be in consultation with local or regional governments from the scientific and ethical perspectives and understanding local culture and more).

When a community is engaged in solving a problem, a solution will be at hand. The importance of this article is that it demonstrates a successful solution when the community is purposely and meaningfully involved, consulted, informed, and gives its consent to a solution. Political leaders, health-care leaders, religious leaders, and the local citizenry must be engaged; to allow this is ethical and right behavior. Communities do not mind getting help, but that help must come in the form of a culturally competent partnership, and it must be sustainable. The Involved Citizen Project was successful because the community identified the problem, or at least agreed with the identification of the problem, participated in the solution and was engaged in the implementation of the solution. Furthermore, the outside forces that were assisting the community were committed to a sustainable solution. Such informal models can be the basis for more formal emergency care delivery systems in future.

  References Top

Tran TT, Lee J, Sleigh A, Banwell C. Putting culture into prehospital emergency care: A systematic narrative review of literature from lower middle-income countries. Prehosp Disaster Med 2019;34:510-20.  Back to cited text no. 1
De Wulf A, Alluisio AR, Hecht BL, Bloem C. Development and implementation of a first responder program. Int J Acad Med 2019;10-21.  Back to cited text no. 2
World Health Organization. Injuries and Violence: The Facts. Geneva: World Health Organization; 2010. Available from: https://www.who.int/violence>_injury_prevention/key_facts/en. [Last accessed on 2020 Mar 10].  Back to cited text no. 3
Fulton BD, Scheffler RM, Sparkes SP, Auh EY, Vujicic M, Soucat A. Health workforce skill mi and task shifting in low income countries: A review of recent evidence. Hum Resour Health 2011;9:1.  Back to cited text no. 4
New York Times Editorial Board. Here Comes the Coronavirus Pandemic. New York Times; February 29, 2020. Available from: https://www.nytimes.com/2020/02/29/opinion/sunday/corona-virus-usa.html. [Last accessed on 2020 Mar 01].  Back to cited text no. 5
World Health Organization. Ebola Virus Disease—Democratic Republic of the Congo. Geneva: World Health Organization; 2020. Available from: https://www.who.int/csr/don/06-february-2020-ebola-drc/en/. [Last accessed on 2020 Mar 01].  Back to cited text no. 6
Papadimos TJ, Marcolini EG, Hadian M, Hardart GE, Ward N, Levy MM, et al. Ethics of outbreaks position statement. Part 1: Therapies, treatment limitations, and duty to treat. Crit Care Med 2018;46:1842-55.  Back to cited text no. 7
Papadimos TJ, Marcolini EG, Hadian M, Hardart GE, Ward N, Levy MM, et al. Ethics of outbreaks position statement. Part 2: Family-centered care. Crit Care Med 2018;46:1856-60.  Back to cited text no. 8
Lu S. Protecting the Truth about the Coronavirus in China. The Nation; February 6. Available from: https://www.thenation.com/article/world/china-journalism-coronavirus/. [Last accessed on 2020 Mar 01].  Back to cited text no. 9
Eskin F, Nichol B. Training the trainer. Public Health 1980;94:133-43.  Back to cited text no. 10


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