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W2896480319 abstract "Underserved communities exist both domestically and internationally. Underserved populations internationally suffer from unclean water, lack of medical providers, or access to care. Although every country has underserved populations, every country has their own interpretation of what this means.1Doherty G.W. Cross-cultural counseling in disaster settings.The Australasian Journal of Disaster and Trauma Studies. 1999; 1999 (Available at:) (Accessed June 6, 2018)http://www.massey.ac.nz/∼trauma/issues/1999-2/doherty.htmGoogle Scholar Over four million people worldwide lack access to quality health services, in large part because of a huge shortage, imbalanced skill mix, and uneven geographical distribution of health workers.2World Health Organization. Education and training. 2013. Available at: https://whoeducationguidelines.org/sites/default/files/uploads/WHO_EduGuidelines_20131202_web.pdf. Accessed June 6, 2018.Google Scholar In the World Health Report 2017, it was estimated that approximately one-half of the global population lives in rural areas. Of the 43.5 million health workers in the world, it is estimated that 20.7 million are nurses and midwives, yet 50% of World Health Organization (WHO) Member States report to have less than 3 nursing and midwifery personnel per 1000 population (about 25% report to have less than 1 per 1000), according to the 2017 Global Health Observatory. Over 45% of WHO Member States report to have less than 1 physician per 1000 population3World Health Organization. Global health observatory data. 2016. Available at: http://apps.who.int/gho/data/node.main.A1444. Accessed June 6, 2018.Google Scholar (Appendix 1). The United Nations (UN) World Populations Prospects lists the 10 countries with the largest populations and projects population growth over time (Table 1.).4United Nations. World populations prospect 2017. Available at: https://esa.un.org/unpd/wpp/Publications/Files/WPP2017_DataBooklet.pdf. Accessed June 6, 2018.Google Scholar This, of course, leads to increasing numbers of underserved and medical disparities, thus increasing the health care burden (Fig. 1).Table 1UN predicted populationsFrom United Nations. World Populations Prospects 2017 Revision. Available at: https://esa.un.org/unpd/wpp/Publications/Files/WPP2017_DataBooklet.pdf. Accessed June 6, 2018.Ten Countries with the Largest Populations, 2017 and 2050RankCountry2017 Population (Millions)Country2050 Population (Millions)1China1410India16592India1339China13643United States of America324Nigeria4114Indonesia264United States of America3905Brazil209Indonesia3226Pakistan197Pakistan3077Nigeria191Brazil2338Bangladesh165Bangladesh2029Russian Federation144Dem. Rep. of the Congo19710Mexico129Ethiopia191Among the ten most populous countries of the world today, one is in Africa (Nigeria), five are in Asia (Bangladesh, China, India, Indonesia, and Pakistan), two are in Latin America (Brazil and Mexico), one is in Northern America (United States of America), and one is in Europe (the Russian Federation). Amongst these, Nigeria's population, currently the seventh largest in the world, is growing the most rapidly and is projected to surpass that of the United States shortly before 2050. In 2050, the populations in six of the ten largest countries are expected to exceed 300 million: China, India, Indonesia, Nigeria, Pakistan, and United States of America (in alphabetical order). Open table in a new tab Among the ten most populous countries of the world today, one is in Africa (Nigeria), five are in Asia (Bangladesh, China, India, Indonesia, and Pakistan), two are in Latin America (Brazil and Mexico), one is in Northern America (United States of America), and one is in Europe (the Russian Federation). Amongst these, Nigeria's population, currently the seventh largest in the world, is growing the most rapidly and is projected to surpass that of the United States shortly before 2050. In 2050, the populations in six of the ten largest countries are expected to exceed 300 million: China, India, Indonesia, Nigeria, Pakistan, and United States of America (in alphabetical order). Working as a Physician Assistant (PA) abroad, I have had the opportunity to work with the underserved internationally. I have had a wide range of opportunities. These vary from setting up clinics in remote locations, to sponsoring local villages, to performing medical needs assessments, to working in disaster zones, and to remotely assisting in evacuation. In all of these situations, the goal is to help create sustainability, educate, and work toward improving safety. Many underserved populations would never call themselves underserved. In many remote areas, such as when I was working in Nepal after the earthquake in 2015, the village I was helicoptered into to provide medical care pulled together and rebuilt their community. They supported each other; they sought out others in other remote villages to let them know that we were on the ground providing medical assistance for those in need. This area in the Ganesh mountain chain was a four-day walk to Kathmandu with strenuous changes in altitude. Villagers relied on each other to provide care, to bandage, and to emotionally support each other after the trauma and losses they sustained. When working abroad in times of disaster, sometimes you are only able to provide temporary care; however, there are plenty of opportunities for education, which we hope lasts a lifetime. There is also the psychological component, whereby people here now know they are not alone. Previously, there has been much discussion as to whether PAs should be working internationally in countries that do not recognize the profession. There is the question of medical liability. What do you do if something goes wrong? Will a PA be blamed publicly and it may look bad for the profession? Will people understand what a Physician Assistant is? What type of liability insurance does one carry? Will people sue you if they don’t know/understand the care that you are providing them, and what if that care is not able to be obtained? There are many criticisms to this; however, if one is trained, has a supervising MD in some capacity, then why would we do people a disservice by not providing care, when we are fully capable and they are more than willing to accept it? Advanced practice providers similar to PAs have worked throughout history taking care of the underserved. Feldshers in Russia, barefoot doctors in China, and military corpsman were some of the first “midlevel” providers.5Ballweg R. History of the profession and current trends. In: Physician assistant: a guide to clinical practice.6th edition. Elsevier, Philadelphia2018: 6-24Google Scholar PAs are present in Australia, India, the Netherlands, Liberia, New Zealand, Germany, Saudi Arabia, Afghanistan, Israel, Ireland, and Canada. Physician associates work in the United Kingdom, medical associates in Ghana, and clinical associates in South Africa.6Kuhns D. International development of the physician assistant profession. In: Physician assistant: a guide to clinical practice.6th edition. Elsevier, Philadelphia2018: 25-36Google Scholar More and more countries are becoming accustomed to the advanced practice provider. In the past several years, increasing conflicts have arisen, and as many as 20 people are forcibly displaced every minute as a result of conflict or persecution. Many displaced persons end up in refugee camps and are totally dependent on humanitarian aid. They fall susceptible to disease, physical and sexual abuse, and human trafficking.7Atiyeh B.S. Gunn S.W.A. Refugee camps, fire disasters, and burn injuries.Ann Burns Fire Disasters. 2017; 30: 214-217PubMed Google Scholar Advanced practice providers can and have played a huge role in providing care to these camps and internationally filling the gap. The American Academy of Physician Assistants (AAPA) in 2016 has reaffirmed their guidelines for an international standard for a code of conduct for PAs practicing internationally (Box 1). While PAs should only provide care in their scope of practice, PAs may be called upon to play many other roles.8AAPA. Guidelines for ethical conduct for the PA profession. 2013. Available at: https://www.aapa.org/wp-content/uploads/2017/02/16-EthicalConduct.pdf. Accessed June 6, 2018.Google Scholar, 9AAPA. American Academy of Physician Assistants Policy Manual. 2016. Available at: https://www.aapa.org/wp-content/uploads/2017/02/International-Policy.pdf. Accessed June 6, 2018.Google Scholar These roles include logistical support and aiding in communication to receiving hospitals, local governances, other nongovernmental organizations (NGOs), and other global entities, such as the UN and the WHO to report statistics to.Box 1American Academy of Physician Assistants guidelines for Physician Assistants working internationallyAAPA: Guidelines for PAs Working Internationally: HP-3700.3.0 International [Adopted 2001, reaffirmed 2006, amended 2011, reaffirmed 2016]1.PAs should establish and maintain the appropriate physician-PA team2.PAs should accurately represent their skills, training, professional credentials, identity, or service both directly and indirectly3.PAs should provide only those services for which they are qualified via their education and/or experiences, and in accordance with all pertinent legal and regulatory processes4.PAs should respect the culture, values, beliefs, and expectations of the patients, local health care providers, and the local health care systems5.PAs should be aware of the role of the traditional healer and support a patient’s decision to utilize such care6.PAs should take responsibility for being familiar with, and adhering to, the customs, laws, and regulations of the country where they will be providing services7.When applicable, PAs should identify and train local personnel who can assume the role of providing care and continuing the education process8.PA students require the same supervision abroad as they do domestically9.PAs should provide the best standards of care and strive to maintain quality abroad10.Sustainable programs that integrate local providers and supplies should be the goal11.PAs should assign medical tasks to nonmedical volunteers only when they have the competency and supervision needed for the tasks for which they are assigned AAPA: Guidelines for PAs Working Internationally: HP-3700.3.0 International [Adopted 2001, reaffirmed 2006, amended 2011, reaffirmed 2016]1.PAs should establish and maintain the appropriate physician-PA team2.PAs should accurately represent their skills, training, professional credentials, identity, or service both directly and indirectly3.PAs should provide only those services for which they are qualified via their education and/or experiences, and in accordance with all pertinent legal and regulatory processes4.PAs should respect the culture, values, beliefs, and expectations of the patients, local health care providers, and the local health care systems5.PAs should be aware of the role of the traditional healer and support a patient’s decision to utilize such care6.PAs should take responsibility for being familiar with, and adhering to, the customs, laws, and regulations of the country where they will be providing services7.When applicable, PAs should identify and train local personnel who can assume the role of providing care and continuing the education process8.PA students require the same supervision abroad as they do domestically9.PAs should provide the best standards of care and strive to maintain quality abroad10.Sustainable programs that integrate local providers and supplies should be the goal11.PAs should assign medical tasks to nonmedical volunteers only when they have the competency and supervision needed for the tasks for which they are assigned The PA may be assisting in setting up the clinic, anything from setting up a basic tent and tarp to a Western Shelter, scoping out and drawing the site for a helicopter pad, to working with incident command structures (Fig. 2).10FEMA. National incident management system. An introduction. Available at: https://emilms.fema.gov/is700anew/index.htm. Accessed June 6, 2018.Google Scholar, 11National Incident Management System. Homeland Security. 2008. Available at: https://www.fema.gov/pdf/emergency/nims/NIMS_core.pdf. Accessed June 6, 2018.Google Scholar, 12FEMA. Department of Homeland Security. 2012. Available at: https://training.fema.gov/emiweb/is/icsresource/assets/so_pcl.pdf. Accessed June 6, 2018.Google Scholar The PA may be a part of the medical team, where the PA functions in their typical role as a medical provider, or as the safety officer, or one of the safety officer’s assistants. The safety officer handles everything from unsafe work environments to personal protection equipment (PPE), ensures adequate sanitation and safety in food preparations, and listens in on tactical options being considered.12FEMA. Department of Homeland Security. 2012. Available at: https://training.fema.gov/emiweb/is/icsresource/assets/so_pcl.pdf. Accessed June 6, 2018.Google Scholar The safety officer (see Fig. 2) may also ensure that risk management addresses safety, occupational health, and environmental health at all levels.12FEMA. Department of Homeland Security. 2012. Available at: https://training.fema.gov/emiweb/is/icsresource/assets/so_pcl.pdf. Accessed June 6, 2018.Google Scholar, 13National Guard Regulation 500-3/Air National Guard Instruction 10-2503. Emergency employment of army and other resources. Weapons of mass destruction civil support team management. Unclassified. 2011. Available at: http://www.ngbpdc.ngb.army.mil/pubs/10/angi10_2503.pdf. Accessed June 6, 2018.Google Scholar The PA may handle everything from medical care to digging latrines, and ensuring safe water sources. Licensure for PAs practicing abroad with the underserved is a common question. In situations such as disaster, this may be waived, or you are working with an MD on your disaster team that supervises you. A PA should contact the Ministry of Health in the country or discuss options with the organization they are working with. The PA may also establish a relationship with a provider in the host country or their supervising physician in their established practice. Section HP-3700.3.1 of AAPA’s policy manual states that PAs must establish the appropriate physician-PA team.9AAPA. American Academy of Physician Assistants Policy Manual. 2016. Available at: https://www.aapa.org/wp-content/uploads/2017/02/International-Policy.pdf. Accessed June 6, 2018.Google Scholar There are no established laws for PAs practicing in underserved areas internationally.14Kuhns D. International health care. In: Physician assistant: a guide to clinical practice.6th edition. Elsevier, Philadelphia2018: 581-590Google Scholar, 15AAPA. The physician assistant in disaster response. 2006. Available at: http://www2.wpro.who.int/internet/files/eha/toolkit/web/Technical%20References/Human%20Resources/The%20Physician%20Assistant%20in%20Disaster%20Response%20Guidelines.pdf. Accessed June 6, 2018.Google Scholar It is recommended to bring photocopies of your licenses, passport, and vaccines as local government and NGO agencies, hospitals, and land border control may wish to keep a copy. When working with the underserved, will they sue? When working in a US hospital Emergency Department in an underserved area, we had a woman who would constantly visit and threaten to sue; she even would phone the Chief Medical Officer of the hospital and tell them of her care that she didn’t approve of. When working internationally with the underserved, it feels like there will be less of a chance to be sued; however, one should not take that chance. Liability for a PA comes into question here, as is it the PA’s personal coverage or the doctor or organization that they are working with? Will the liability insurance policy even cover you internationally? It is recommended that PAs look into their own personal coverage. Checking with the Ministry of Health in that country or a local consulate is also recommended. In times of a disaster, this may be waived. Certain countries, such as Tahiti, require you to work under the supervision of a French Polynesian trained doctor, no matter their specialty. This holds true for physicians as well as PAs. PAs should also keep in mind that Good Samaritan laws do not provide either authorization to practice or, in most cases, liability protection when they are working in disaster relief situations.15AAPA. The physician assistant in disaster response. 2006. Available at: http://www2.wpro.who.int/internet/files/eha/toolkit/web/Technical%20References/Human%20Resources/The%20Physician%20Assistant%20in%20Disaster%20Response%20Guidelines.pdf. Accessed June 6, 2018.Google Scholar Certain countries honor the Good Samaritan law, such as Tahiti, Australia, and the Philippines; however, Australia has multiple different states, and one should check specifically before providing care.16Pardun JT. Good Samaritan laws: a global perspective. 20 Loy. L.A. Int'l & Comp. L. Rev. 591. 1998. Available at: http://digitalcommons.lmu.edu/ilr/vol20/iss3/8. Accessed June 6, 2018.Google Scholar Some of these countries will honor a medical mission under the law; however, one should always make sure to check with the above agencies first and have it in writing. One of the other big factors to address when working in an underserved area is that medicines may not be readily available. A provider may not be familiar with the local medications either. Medical providers cannot haul large amounts of medications in without being given the proper permissions. When working in Indonesia, I met with the local consulate to receive permission to bring in the medications that were necessary. Upon entering the country, Indonesia has a sign that says death penalty for bringing in drugs (Fig. 3). In Fiji, one must contact the Ministry for approval; however, customs still have the right to search you and may detain your goods. In previous trips to underserved areas, I have a full itemized list of what is being brought in; I have the consulate review and stamp their seal of approval. It is not always easy to get appointments with consulates nor are they always readily accessible in smaller towns. Pill bottles should always be labeled, and a provider should always carry their medical license and copies of it in case of being detained at customs. In Japan, Vicks and Sudafed are illegal due to containing pseudoephedrine. In Costa Rica, you may only bring in enough meds for the length of your stay with a doctor’s note. In Hong Kong and Greece, codeine is illegal. Tramadol may get you imprisoned in Egypt. Drug resistance in an underserved area should also be noted. If a provider enters the country and tries to prescribe a resistant antibiotic, they are not of service and are adding to the crisis. PAs should also be aware of drug dosages. When administering medications in Tahiti, the measurements were not the same. In a comparison, between Japan, Europe, and the United States, multiple differences in approved dosing for drugs exist.17Malinowski H.J. Westelinck A. Sato J. et al.Same drug, different dosing: differences in dosing for drugs approved in the United States, Europe, and Japan.J Clin Pharmacol. 2008; 48: 900-908Crossref PubMed Scopus (64) Google Scholar, 18Arnold F.L. Kusama M. Ono S. Exploring differences in drug doses between Japan and Western countries.Clin Pharmacol Ther. 2010; 87: 714-720Crossref PubMed Scopus (55) Google Scholar A provider must also understand that what you might wish to give a patient is a nonsteroidal anti-inflammatory drug, but they may want an herbal lotion or an ointment instead. Many developing countries are increasingly dependent on donor assistance to meet the equipment needs of their health care systems.19WHO. Guidelines for medicine donations. 2010. Available at: http://apps.who.int/iris/bitstream/handle/10665/44647/9789241501989_eng.pdf?sequence=1. Accessed June 6, 2018.Google Scholar, 20WHO. Guidelines for health care equipment donations. 2000. Available at: http://www.who.int/medical_devices/publications/en/Donation_Guidelines.pdf. Accessed June 6, 2018.Google Scholar A provider must think before bringing in supplies to another country. Will the community know how to use the supplies? Are they reusable? Will harm occur to them if they run out? The WHO has donation guidelines. These guidelines include that the health care equipment donation should benefit the recipient to the maximum extent possible; a donation should be given with the respect and wishes of the recipient and governing/administrative policies. There should be no double standard of care—if the item is unacceptable in the donor’s country, then it is also unacceptable in the receiving country. And, last, there should be effective communication between the donor and the recipient, with all donations resulting from a need expressed by the recipient. Donations (solicited) should never be sent unannounced.21Health and Human Services. NDMS 2060. Personal gear for deployments. Unclassified. 2013. Available at: https://respondere-learn.hhs.gov/file.php/123/N_2060/NDMS-N-2060-Full-b_Rev_2013.pptx, https://respondere-learn.hhs.gov/mod/resource/view.php?id=4302. Accessed June 6, 2018.Google Scholar There are also certain organizations that will help you transport medical supplies into different countries or provide you with prepackaged travel packs. In Haiti, after the 2010 earthquake, drugs and supplies were shipped in containers. There were tons of containers at the airport and all over the tarmacs. There was no one to empty them, nor did anyone know where they were best suited. Bringing in all of the supplies does not mean that the community knows what to do with them. While working in a remote island in the Philippines, we taught over 100 people basic life support. We purchased two automated external defibrillators and gave one to the clinic and one to the Coast Guard and trained them how to use them. While you can tell people what to do, that does not mean they know how to do it. Teaching and demonstrating how to perform certain tasks and how to use drugs/supplies and where they could be best utilized are key. One of the most important things working in underserved environments is to understand resource utilization. One must work with what is given to them. They must understand how to triage who needs what. There is not an unlimited supply. You can’t just call central supply and have something delivered to you within the hour. One may reuse c-collars; sterilization may vary, and clinics may soak needles and sutures in Chlorhexidine for 14 days before reusing them. In Malawi, the hospital would send people to the pharmacy to buy clean needles to ensure that they were given them. Providers who are accustomed to working in a hospital will need to think outside of the box. They will need to set up their own water filtration systems, such as the ones from Waves4Water; they will need to use old bottles to collect rain water to help with delivery of babies, irrigate wounds, and utilize during surgery. In Haiti, the surgeon and I couldn’t close the abdomen due to abdominal compartment syndrome and we didn’t have Vac-packs or even an operating table, so we utilized a take on the Bogota bag, by cutting empty saline bags and sewing them to the skin and sterile wet towels on top of, all while operating on a table with a wood plank as our bed (Fig. 4D). We also ran out of Foley catheter bags, so we used gloves instead (Fig. 4B). In Nepal, we created a walking boot out of an extra Sharps box (Fig. 4C). In Africa, an intracranial pressure (ICP) monitor was created with tubing and cardboard (Fig. 4A). What do you pack for yourself? A provider going to work abroad with the underserved should take what you can carry and no more than that. You will need to be able to take care of yourself. In Nepal, we had to allot for weight on the helicopters that were flying into treacherous areas with high wind gusts. Several helicopters had crashed in that region within the week. We also had to be prepared to hike steep elevation gains with our gear on our back. You cannot rely on having someone carry your bags. The US federal government recommends MOUSE, an acronym which means: mobile, organized, utility, safety and self, and environment. This means you must be able to move with your gear, know where stuff is in your bag, have appropriate tools such as work gloves, duct tape, and a travel shovel with you. Safety should include N95 and PPE. Self includes meals ready to eat (MREs), eyeshades, earplugs, raingear, water filtration, hand hygiene kits, first-aid kit, and personal medications. Environment means one should have sturdy boots and clothing that suits the 3W’s: wicking, warmth, weather.22Health and Human Services. NDMS 2040. Cultural awareness. Unclassified. 2018. Available at: https://respondere-learn.hhs.gov/file.php/123/NDMS-NC-2040-Full-rev1.pps, https://respondere-learn.hhs.gov/mod/resource/view.php?id=4300. Accessed June 6, 2018.Google Scholar I have included a pack list (Appendix 2). I also recommend carrying a wire saw, which can cut anything from a piece of paper to tree limbs for firewood, and can be use for limb amputation. I also recommend packing your happy foods (remember that chocolate melts); a mixture of goji berries, cacao, and goldenberries is a great superfood that packs well in a Ziplock bag. One should also remember cash/local currency, as many locations will not have access to ATMs. Working in Haiti after the earthquake as a PA, I communicated with the military hospital ship, the SS Comfort, as well as worked with hospitals along the US east coast transporting patients out that needed emergency care. In underserved areas, one typically works with the resources that they are given; however, there are those few times when one can really make a difference and organize a patient to be evacuated. In Nepal, we got report that a pregnant woman who we saw the day before was seizing. We were able to organize a helicopter and deliver mother and baby safely in Kathmandu. The local midwife was not present, and we were able to arrange transport, so we did. This does not always happen. You must be sensitive that you are separating families as well as working with agencies to allow noncitizens right of entry into the country for medical care. Evacuation insurance for yourself should be also be purchased. What happens if you break your leg or become ill? Make sure you and your family have a plan of action and make sure someone knows where you are at. GPS satellite devices such as SPOT can send out messages to those you designate on your list to let them know you are safe. SPOT also has tracking so those at home can see where you are located on a map when you ping the device. One thing you will find is that written record is very common in underserved areas. Normally, this is quite difficult; however, after a disaster, this becomes very difficult. Families from other locations do not know if the person is alive or not. Patients in Haiti after the earthquake did not have any records of who they were. I went through over 400 patients creating a medical record system so that people would know who they were. This also becomes very difficult as these patients don’t have records of owning their homes, bank records, or identification/passports to be evacuated. It is advisable that when working in an underserved area that you counsel your patients to have backup records. Overcoming cultural barriers is another factor one must take into consideration. Providers may need to use translators. They may have to use other words as words might not exist in the patient’s language. One must be considerate as eye contact, touch, and gestures vary from culture to culture. Expressions of pain may differ. Patients may speak in tongues when in pain. While working in Africa, patients postoperation did not have a patient-controlled analgesia pump for pain. They did not take pain medicine. Attitudes toward pain may be very stoic. Every culture has its own way of responding to important life events, such as birth, puberty, childbearing, illness, disease, and death. Cultural norms affect the way people react when they face the stresses of crises, disasters, ill health, detention, and uncertain futures.22Health and Human Services. NDMS 2040. Cultural awareness. Unclassified. 2018. Available at: https://respondere-learn.hhs.gov/file.php/123/NDMS-NC-2040-Full-rev1.pps, https://respondere-learn.hhs.gov/mod/resource/view.php?id=4300. Accessed June 6, 2018.Google Scholar In Nepal after the earthquake that destroyed their village and killed their loved ones in front of their very eyes, they sat in circles and played music and hand-clapping games and sang together. It was their way of coping. It was what they knew how to do (Fig. 5). Foods are part of every culture. Patients may eat hot, spicy, kosher, vegetarian, and meals different than you are accustomed to. They may not want to stop eating certain foods that you recommend not to eat, or they may believe certain foods may cure them. In many cultures, refusing food offered to you is a sign of disrespect. One should pay attention to religious beliefs, appropriate dress, cultures that are male dominant, and attitudes toward menstruation. Many women are not allowed to live in their homes when it is that time of month. Many cultures believe that when inflicted with disease it is due to some causality. Deuteronomy 28:20-22 states that, because of various transgressions, God strikes people with diseases, fever, and inflammation.23Manguvo A. Mafuvadze B. The impact of traditional and religious practices on the spread of" @default.
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