Heather Lukolyo

Mapping the Epidemiology of Kaposi Sarcoma and Non-Hodgkin Lymphoma Among Children in Sub-Saharan Africa: A Review

Children with human immunodeficiency virus (HIV) have an increased risk of developing Kaposi Sarcoma (KS) and non‐Hodgkin lymphoma (NHL) compared to HIV‐negative children. We compiled currently published epidemiologic data on KS and NHL among children in sub‐Saharan Africa (SSA). Among countries with available data, the median incidence of KS was 2.05/100,000 in the general pediatric population and 67.35/100,000 among HIV‐infected children. The median incidence of NHL was 1.98/100,000 among the general pediatric population, while data on NHL incidence among HIV‐infected children were lacking. Larger regional studies are needed to better address the dearth of epidemiologic information on pediatric KS and NHL in SSA.

Global Health: Preparation for Working in Resource-Limited Settings

In this article, the authors outline the scope of provider involvement in GH, highlight specific considerations and issues, and summarize preparation recommendations from the literature. Trainees and clinicians from high-income countries are increasingly engaging in global health (GH) efforts, particularly in resource-limited settings. Concomitantly, there is a growing demand for these individuals to be better prepared for the common challenges and controversies inherent in GH work. This is a state-of-the-art review article in which we outline what is known about the current scope of trainee and clinician involvement in GH experiences, highlight specific considerations and issues pertinent to GH engagement, and summarize preparation recommendations that have emerged from the literature. The article is focused primarily on short-term GH experiences, although much of the content is also pertinent to long-term work. Suggestions are made for the health care community to develop and implement widely endorsed preparation standards for trainees, clinicians, and organizations engaging in GH experiences and partnerships.

Authorship in Pediatric Research Conducted in Low‐ and Middle‐Income Countries: Parity or Parasitism?

Interest in global health has increased greatly in the past two decades. Concomitantly, the number and complexity of research partnerships between high‐income (HIC) and low‐ and middle‐income countries (LMICs) has grown. We aimed to determine whether there is authorship parity (equitable representation and author order) or parasitism (no authors from study countries) in paediatric research conducted in LMICs.

Partnerships for Global Child Health

This literature-based expert consensus review presents the definition, scope, genesis, evolution, and models of GCH partnerships, including benefits and challenges, guiding principles and core practices. Child mortality remains a global health challenge and has resulted in demand for expanding the global child health (GCH) workforce over the last 3 decades. Institutional partnerships are the cornerstone of sustainable education, research, clinical service, and advocacy for GCH. When successful, partnerships can become self-sustaining and support development of much-needed training programs in resource-constrained settings. Conversely, poorly conceptualized, constructed, or maintained partnerships may inadvertently contribute to the deterioration of health systems. In this comprehensive, literature-based, expert consensus review we present a definition of partnerships for GCH, review their genesis, evolution, and scope, describe participating organizations, and highlight benefits and challenges associated with GCH partnerships. Additionally, we suggest a framework for applying sound ethical and public health principles for GCH that includes 7 guiding principles and 4 core practices along with a structure for evaluating GCH partnerships. Finally, we highlight current knowledge gaps to stimulate further work in these areas. With awareness of the potential benefits and challenges of GCH partnerships, as well as shared dedication to guiding principles and core practices, GCH partnerships hold vast potential to positively impact child health.

Beyond the learning curve: length of global health electives.

Medical students and residents from resourced regions are increasingly seeking clinical rotations in resource-limited settings abroad. This interest has been matched by increased opportunities in many residency programs in the United States for residents to participate in global health electives (GHEs). Global health electives provide learners with opportunities to practice and learn within global health settings. This enhances their knowledge of local diseases and disease processes, leads to improved physical exam skills with decreased reliance on labs and other testing, and demonstrates the importance of communication across cultures and languages. In addition, studies have shown that short-term learners (STLs) who participate in GHEs are more likely to practice primary care medicine, obtain public health degrees, and practice medicine amongst underserved populations in their home countries.1 In 1999, the American Academy of Pediatrics (AAP) recommended that GHEs last a minimum of four weeks to allow learners to assimilate into the culture and maximize their time abroad.2 Currently, GHEs offered in pediatric residency programs range from three to eight weeks in length.3 To our knowledge there have been no discussions about the reasons for the recommended duration of four weeks for GHEs. We aimed to describe how clinical productivity of STLs varies by consecutive working days on a GHE. Evaluating global health rotation length The Baylor International Pediatric AIDS Initiative at Texas Children’s Hospital clinical network is the largest network of pediatric HIV clinics worldwide.4 Short-term learners from institutions in North America have been completing GHEs at the Baylor College of Medicine Bristol-Myers Squibb Children’s Clinical Centre of Excellence - Swaziland (Baylor-Swaziland) since 2006. In 2010, 26 STLs completed GHEs at Baylor-Swaziland, including medical residents, medical students, and non-clinical learners. Short-term learners spent two to four weeks with Baylor-Swaziland. The electronic medical records in Swaziland from 2010 were reviewed to assess the total number of patient encounters completed by both resident or fellow STLs and clinical preceptors per day. Based on the number of patient encounters per medical resident learner per day, there was a sequential increase in the number of patient encounters with more sequential workdays of the rotation. The number of patient encounters per day did not vary by level of STL training, with residents in their second, third, and fourth years of residency completing similar numbers of patient encounters per day. The number of patients seen by two different expatriate clinical preceptors during a one-month period was not affected by mentoring STLs. From our observations, STLs completed more patient encounters per day over time. This suggests that there is an inherent learning curve during a GHE. While the AAP currently recommends that GHEs last four weeks, longer rotations may offer STLs additional time to contribute to their site in meaningful ways. Studies assessing host preceptors’ perceptions of STLs have shown a preference for rotations lasting four to six weeks.5 Other studies have suggested an even longer elective length between two and three months,6 which may offer more opportunities to master a range of competencies in a global health setting. The learning curve we observed is likely due to a combination of operational, clinical, and cultural-linguistic factors. Operational factors include becoming familiar with the electronic medical record, clinic flow, and clinic processes. The concept of a learning curve in residency has been demonstrated in several fields.7 However, in a setting such as Swaziland, there are many clinical factors that STLs may not have encountered before. These include unfamiliarity with diseases that are less commonly encountered in the home setting, not being well versed in local or international clinical guidelines, not knowing the available medications, and inexperience working within resource limitations. Particularly in the Baylor-Swaziland clinic setting, management of pediatric HIV is unfamiliar to most STLs. Short-term learners are also likely to encounter some degree of cultural adjustment or emotional challenges in the new environment which may impact clinical productivity. In addition, language barriers and the need to use an interpreter during clinical encounters likely hinders productivity. Though our findings suggest that longer rotations may allow learners to get over the initial learning curve, there are many barriers to increasing rotation length for trainees. These include providing adequate call coverage at the home institution, funding of resident salaries when they are away, and restrictions by the Accreditation Council of Graduate Medical Education on time away.8 It would be ideal for programs to have the flexibility to have call- and continuity clinic-free months without jeopardizing accreditation or causing burdens on fellow residents. Furthermore, some residency programs require vacation to be taken during GHEs, further shortening actual time spent at host clinical sites. Between vacation, travel time, weekends, and possible public holidays, the actual clinical experience may be as short as ten working days or less. According to a recent survey of residents, 57% would not be willing to give up vacation time during international electives.9 Nevertheless, requiring residents to do so may have the favorable effect of selecting for those residents who are most dedicated to or interested in global health, which has been cited by international host preceptors as a desirable trait of STLs completing GHEs at their sites.10 Interestingly, the number of patient encounters per day did not vary by medical resident training level. This supports the argument that everyone, regardless of medical resident year of training, encounters an initial learning curve. Reassuringly, STLs in our study did not appear to hinder clinical preceptor productivity in terms of patient encounters per day. This is in contrast to other reports in which there was perceived efficiency burden on clinical preceptors of STLs.10 These differing findings may be explained by the measure of clinical efficiency (i.e. self-perceived versus directly measured). Additionally, STL mentoring tasks may detract from other non-clinical administrative roles that preceptors have in their clinics. Finally, the lack of hindrance on productivity could be because the host preceptors at Baylor-Swaziland were expatriate clinicians who may have had greater understanding of STLs’ capabilities and training background.

Host clinical preceptors’ perceptions of professionalism among learners completing global health electives

Objectives This study aims to gain an understanding of the perceptions of host clinical preceptors in Malawi and Lesotho of the professionalism exhibited by short-term learners from the United States and Canada during short-term global health electives. Methods Focus group discussions were conducted with 11 host clinical preceptors at two outpatient pediatric HIV clinics in sub-Saharan Africa (Malawi and Lesotho). These clinics host approximately 50 short-term global health learners from the United States and Canada each year. Focus group moderators used open-ended discussion guides to explore host clinical preceptors’ perceptions of the professionalism of short-term global health learners. Thematic analysis with an inductive approach was used to identify salient themes from these focus group discussions. Results Eleven of the 18 possible respondents participated in two focus group discussions. Adaptability, eagerness to learn, active listening, gratitude, initiative, and punctuality was cited as professional behaviors among short-term global health learners. Cited unprofessional behaviors included disregard of local clinicians’ expertise and unresponsiveness to feedback. Host clinical preceptors described difficulty providing feedback to short-term global health learners and discrepancies between what may be considered professional in their home setting versus in the study settings. Respondents requested pre-departure orientation for learners and their own orientation before hosting learners. Conclusions Both host clinical preceptors and short-term global health learners should be aware that behaviors that may be considered best practice in one clinical setting may be perceived as unprofessional in another. Future studies to develop a common definition of professionalism during short-term global health electives are merited.

Global Is Local: July at a Teaching Hospital in Texas

It was 1:00 am. I was the supervising resident on the Pediatric Hospital Medicine service at my home institution in Houston, Texas just a few months after returning from Uganda, where I had spent a clinical year as part of my combined residency program in pediatrics and global child health. I returned a page from the emergency department: “We have a 10-year-old girl* to admit. She has a 3-month history of cough, weight loss, night sweats, fevers, and a positive quantiferon test. She and all her family members also have a skin rash that looks like scabies. She is stable from a respiratory perspective, and we’d like to admit her to your service for further workup and treatment.” I paused as my mind turned to the dozens of patients I treated with pulmonary tuberculosis during my year in Uganda, many of them with the triple burden of tuberculosis, HIV, and malnutrition. “Oh,” the emergency physician added, “and the family is from Rwanda only speaks Kinyarwanda.” I relayed the information to my intern. She was in her first week of residency, adapting to night shift, learning the geography of our large hospital and a new electronic medical record, and steadily managing 1 admission after another while figuring out how to balance cross-coverage duties. She was primed in her new role as doctor to absorb information as quickly as it was offered to …