Padma Swamy

An Advocate’s Well-Child Check

You are seeing a 2 year old child in clinic who presents for their general check-up and vaccines. You find out that he has multiple issues ranging from somatic issues to social issues for which he is presenting today. What do you do first?

The Current State of Global Child Health and Disparities

With the advent of technological advances, there has been increased travel and sharing of knowledge due to globalization (International Monetary Fund Staff 2008). This has resulted in both economic benefits and cultural exchange (International Monetary Fund Staff 2008). This increased travel has also had health implications (International Monetary Fund Staff 2008).

Policy and Advocacy Framework

The answer to this complex question is not as simple as using a dictionary. According to the WHO, health policy are policy that “refer to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society” (World Health Organization 2018a, b). Often policies that may not be delineated in legislature as “health policies” may still affect health in other manners. Dr. Margaret Chan, former Director- General of the World Health Organization, stated that “Policy spheres are no longer distinct. Lines of responsibility are blurred” (Chan 2010). She further goes to cite an example using the industrialization of food production and how the pesticide usage from this can lead to health effects (Chan 2010). Policies are complex and can result in intentional and unintentional effects.

Global Health Disparities in High-Resource Settings

Living in a high resource country or continent does not render one immune to pathology. There is no doubt that the burden of poor health falls on low and middle income countries. According to the WHO the average life expectancy in low income countries is 62 years while in high income countries it is 81 years (World Health Organization 2016). A child from Sierra Leone has a life expectancy of 50 years, while a baby born in Japan on average, will live to 84 years of age (World Health Organization 2016).

Pathologies Disproportionately Affecting the Underserved

In order to understand the pathologies afflicting the underserved an examination of who this population is key. According to the World Bank’s OVC toolkit, children in general are more vulnerable than adults, and some children are more vulnerable than others (World Bank’s Africa Region and World Bank Institute 2005). The World Bank talks about a downward spiral that may put a child at risk (World Bank’s Africa Region and World Bank Institute 2005). The World Bank OVC Toolkit highlights how changes to the social situation can slowly accumulate resulting in children that are disconnected from the family and without support making them the most vulnerable. These children are then at risk for exploitation, living in poor conditions, poor health outcomes, trauma causing mental health issues and many other problems. This situation occurs in many settings all across the world and affects many children.

What Is Global Health

Global Health. Public Health. International Health. A simple Google search or literature review reveals the challenge of defining global health or global child health.

Global Child Health

Arch Dis Child 2011;96:1135–1139. doi:10.1136/archdischild-2011-300628 1135 ABSTRACT Objective To determine the prevalence and predictors of microalbuminuria (MA) (urine albumin-creatinine ratios (ACRs) of 30–300 μg/mg) in children with homozygous sickle cell (Hb SS) disease in Jamaica. Patients and methods 244 children with Hb SS disease were screened for MA. Blood samples and a retrospective review of patient records were used to determine haematological, biochemical and clinical correlates for MA. Results The prevalence of MA was 18.4%. The youngest child with MA was 2.8 years old. The distribution of urine ACRs was right skewed and normalised by natural log transformation. Abnormal urine ACRs ranged from 32 to 260 μg/mg. In univariable analyses with log ACR as outcome, ever having dactylitis (β=0.44; 95% CI 0.08 to 0.80; p<0.02), glomerular hyperfi ltration (β=0.6; 95% CI 0.26 to 0.94; p<0.001), age (β=0.07; 95% CI 0.01 to 0.12; p<0.02), estimated glomerular fi ltration rate (eGFR) (β=0.01; 95% CI 0.005 to 0.02; p<0.001), haemoglobin concentration (β=−0.18; 95% CI −0.34 to −0.02; p<0.03) and haemoglobin F (β=−0.03; 95% CI −0.05 to −0.003; p<0.04) were signifi cantly associated with MA but lactate dehydrogenase (a marker of haemolysis) was not. Adjusting for gender, age (β=0.08; 95% CI 0.02 to 0.15; p=0.01), eGFR (β=0.01; 95% CI 0.001 to 0.01; p=0.03) and body mass index (β=−0.16; 95% CI −0.28 to −0.03; p=0.02) were predictors of MA. Conclusions MA is seen as early as 2.8 years in children with sickle cell disease. Risk factors for MA include glomerular hyperfi ltration, nutritional factors and vaso-occlusion but not haemolysis. Interventions addressing these factors may be useful.

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.

Migrating Children: The Need for Comprehensive Integrated Health Prevention Measures

Purpose of the ReviewMillions of children have migrated across borders with more than half of these children fleeing violence. The purpose of this review is to highlight the health issues that these children face. While the amount of sheer trauma that these children experience is astounding, there are policies and clinical models that could be developed and implemented to improve the health and well-being of these children.Recent FindingsCommunity-based clinical models that provide culturally sensitive health care with links to mental health, legal services, and language services are one way to mitigate the effects of the health inequities that immigrant children and their families face.SummaryA more comprehensive understanding of the effect of resiliency in these children would help to inform interventional programs that could promote resiliency and improve long-term outcomes. As institutional, local, national, and international policy decisions affect the health of migrating children, policies at every level should include provisions for children.