Currently 93% of U.S. medical schools offer programs in international health, and approximately 2,000 U.S. medical students each year take part in elective international health rotations.1 Lofty educational goals for international programs will be frustrated, however, if students and faculty do not know how to be effective in a developing country, and the fact that only 22% of schools with international health programs offer formal preparation for international activities may lead to disappointed participants. This problem can be compounded by the growing interest in international health programs of first- and second-year medical students, whose very limited clinical skills and experience may make it difficult for them to be effective international service providers.6
The Department of Family Medicine at the University of Miami School of Medicine (UMSM) has developed a program to help prepare students for international work and to ensure that the work they do makes a difference. Through Project Medishare, medical students are trained to conduct health fairs; these health fairs are student-organized, one-day events that offer a variety of patient-education and screening services to underserved communities in Haiti. We have found this program to be a very effective way for students interested in international health to have a meaningful learning experience and an opportunity to promote the health of people in a developing country.
Students and faculty at UMSM began concerted volunteer efforts in Haiti shortly after the United Nations embargo was lifted in 1994. There is a large Haitian-American population in Miami, and several UMSM faculty are Haitian or of Haitian ancestry. This nucleus of concerned Haitian-American faculty was complemented by American students and faculty who were moved by the health care crisis in Haiti. This core group formed Project Medishare.9 Project Medishare's initial efforts focused on providing primary care services to Haitian communities, and most early volunteers were faculty and residents in family medicine at Jackson Memorial Hospital. However, UMSM students have a strong tradition of volunteer service,10 and each year more and more medical students volunteered. At the same time, a Haitian-American student from the University of Florida School of Medicine (UFSM), hearing about UMSM's efforts, asked Project Medishare to provide faculty supervision for a planned spring-break trip to Haiti sponsored by the American Medical Student Association.
By the spring of 1995, Project Medishare had identified an orphanage in Port-au-Prince that had no regular source of health care. That year, teams of students and faculty performed much-needed malnutrition screenings and physical examinations for each of the orphans, plotting their heights and weights on growth curves and performing vision screening and developmental assessments. Subsequently, each year students from UMSM and UFSM have returned and conducted more extensive health fairs. The health fair locations now include five orphanages and four rural villages (Kenscoff, Deluge, Decouze, and Thomonde). In each case, the establishment of the annual health fairs was requested by local authorities, who host the students during visits, providing them with lodging and food. In the spring of 1999, 25 UMSM and 28 UFSM students visited Haiti for health fair activities. Eight students returned for a second experience over the summer.
Students begin preparing for the health fairs each fall. They study the history, language, and culture of Haiti in small-group, voluntary seminars prior to their visits. In addition to mastering the required basic science material, UMSM students are taught how to perform a basic history and physical examination in their first year and patient-management skills in their second year. The students also raise funds to support their travel and solicit donations of equipment, medicine, and supplies, which they carry with them.
In the spring, the students are organized into teams that include at least one linguistically competent student, and they are always accompanied by at least one linguistically competent faculty member. Trips generally last a week, providing the opportunity for the teams to conduct health fairs in three or four locations, with travel time in between. On the day of the fair, the students set up health education stations for the services provided. Each session begins with health education classes (a practice we learned from our Haitian colleagues). Services provided at the fair include screening for malnutrition, anemia, and high blood pressure, and screening and treatment for common skin conditions such as scabies and impetigo. Students and patients rotate from station to station. Local authorities are responsible for publicity and security, and any findings requiring follow-up care are referred to local providers.
SUCCESS OF THE PROGRAM
The feedback we have received from Haitian patients and local authorities has been uniformly positive. For many patients, the health care provided at the health fairs is the only medical care they have ever received. Each community for which we have conducted a health fair has invited us back, and the list of communities requesting health fairs is growing each year.
The students are asked to keep journals of their experiences (see the boxed text). As the journals show, the students' experiences in Haiti not only open their eyes to the health problems of developing countries, they also provide insight into the human condition, empower students with the knowledge that their efforts can make a difference, and teach them to provide effective health care in settings with limited resources.
Our first health fair was the smallest, serving 85 children. Since then, the health fairs have seen a range from approximately 100 participants in Delugé to an estimated 600 in Thomonde. The ages of patients have ranged from newborns to a woman in Thomonde self-reported to be 115 years old. At one health fair near Jacmel, 33 children with clinical evidence of malnutrition were identified, and their parents instructed in ways to increase the protein in their diet. Twenty percent of the children screened for anemia have had hemoglobins of 10 g/dL or less. Such patients are started on iron and multi-vitamins and given antihelminthics, and they are retested on subsequent visits. Three hundred sixty-one orphans have been screened for tuberculosis, and the staffs of the orphanages have been instructed in the process of direct observed therapy (DOT) for those children who test positive. Plans for future health fairs include more sophisticated vision screening and provision of eye-glasses to children who need them, specific screening for sickle-cell anemia, and more extensive immunization, in accordance with guidelines from Haiti's Ministry of Health.
The health care conditions in Haiti are the worst in the Western Hemisphere, and among the worst in the world.8 The paradox is that in situations of almost universal need, low-technology interventions such as patient education and health screening can have a profound impact on health. This is obviously an important lesson for students, but one that they have few opportunities to learn in the United States. Several of the interventions focus on such crucial areas as malnutrition, breastfeeding, immunization, and women's health.5,12 The health fair therefore, is a simple method to make first- and second-year students effective providers in a developing country. We believe our experience with health fairs can be generalized beyond Haiti, with the help of some practical suggestions:
1. There must be a “critical mass” of culturally and linguistically competent students and faculty.
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We always identify at least one faculty member and one or two medical students who have the linguistic and cultural competencies to lead the health fair teams in Haiti. It should be noted that originating from one particular country does not guarantee cultural competency. Other issues, such as the social class of the medical practitioner, familiarity with rural life, and willingness to blend formal medical education with local customs, must be factored into the equation in order to create a true intercultural experience.13
Even limited use of the local idiom—in this case, Creole—has been a major asset for our students. Good-natured patients, particularly Haitian students studying English, often volunteer as language teachers and translators, initiating social interaction between the Haitians and the visiting Americans.
It has been our observation that even in a short time (one week), most students rapidly acquire the medical vocabulary needed to conduct a quick assessment. The medical problems identified by the students usually fall within three or four categories, facilitating, in the course of one day, repetitive use of the medical terms, phrases, and expressions necessary for patient education and care.
2. Come at the invitation of and work in collaboration with local organizations and authorities.
Planning a health fair in a foreign country requires obtaining authorization from the host country's Ministry of Health. Knowledge of the rules governing foreign medical practitioners and medical students' scope of practice is imperative to ensure good rapport with the local health authorities. A medical aid program, using U.S. physicians and medical students, might possibly highlight the administrative failings of the host country's medical delivery system or place local medical practitioners in an uncomfortable position. Duplication of services (e.g., immunization) deemed inappropriate by the host-country officials can only create ill feelings despite the underlying good intentions.
A more thoughtful approach is to elicit from the foreign partner an understanding of the public health planning and policies for the area served. Whenever possible, a partnership should be encouraged between the host country's medical students, their preceptors, and local health workers. Such a collaboration will bring added competency in language and cultural bridging, and will establish continuity for the voluntary interventions that would not otherwise be possible in a short period of time.
3. Prepare well in advance, and emphasize interventions that students are technically capable of doing.
In a country such as Haiti, where many people lack even basic health care, it is important to define the scope of the health fair and to refrain from nourishing false hopes. Medical students, abroad and at home, are apprehensive about missing the right diagnosis or dispensing the wrong advice. In a foreign country, they might be incorrectly perceived as universal health care providers capable of resolving both common health problems and complex, long-standing surgical or congenital conditions.
Students will feel powerless if faced with too many unrealistic expectations from their patients; therefore, a clear delineation of services as established with the local partners must be publicized in posters, flyers, and radio announcements advertising the health fairs and explained to the participants at the beginning and during the course of the fair.
4. Try to make each trip a little better than previous trips.
Each day during and frequently after each trip, the medical students meet with their mentors, not only to cement newly created bonds, but also to reflect on their experiences. Each segment of the trip is critiqued to evaluate its educational and service value. Issues discussed include trip logistics, record keeping, safekeeping and dispensing of medications, interaction with local practitioners, and the effectiveness of health education classes.
Key members of the prior trips are invited to join the core committee planning the next trip, working together with new recruits and transmitting the benefits of their newly acquired “veterans” status. Changes in the trip itinerary and in the choices of interventions have been implemented as a direct result of this collaborative approach.
While other articles on international health curricula have focused on learners' content needs,5,6,14,15,16 we have focused on how to prepare students to be effective providers in developing countries. This effectiveness creates an impressive sense of self-confidence in our students. At the same time, the frequent hardships, triumphs over adversity, and opportunities for on-the-spot problem solving forge permanent bonds among students and faculty (the students frequently refer to the trips as “medical outward-bound”). These bonds continue throughout medical school, inspiring students to raise funds for and participate in other international health experiences. Furthermore, the cultural competency skills they learn serve them and their patients (particularly their Haitian patients) well when they return to Miami.
This year, 44 UMSM first- and second-years students have committed to volunteer in Haiti, and another 80 are working on logistic support in Miami. UFSM will be sending 23 students and faculty to Haiti during spring break. A grant to UMSM to establish family medicine residency training in Haiti from the Open Society Institute, while not directly benefiting the student volunteer program, will provide even more opportunities to integrate our activities with those of the Haitian Medical School and Haitian providers, and, we hope, to further improve the health of underserved people in our neighboring country.