Serving Overseas: Volunteer Teaching

Global Focus
Reports From Physician-Volunteers Around the World

Family medicine has become a global movement as a medical specialty. From small beginnings over a half century ago, it has now spread from its Western roots to all continents. The origins of family medicine lie in a long history of general practice in which the only doctor for much of the world was the generalist. Non-governmental organizations (NGOs) as well as governmental organizations (GOs) have contributed immensely to this international movement to improve the health of the world.

Physician-volunteers have joined in many of these efforts. Here, we share some of our experiences as largely volunteer physician-educators as examples of contributions made on a much larger scale by many others.

HOW TO FIND
OPPORTUNITIES TO HELP
If you have ever considered international volunteerism, you can find help from specialty organizations, such as the American Academy of Family Physicians (AAFP); other medical organizations, such as the World Organization of Family Doctors (Wonca) or Doctors Without Borders; or your religious charitable wing if you are a person of faith. There are literally thousands of NGOs and GOs that could benefit from your help—from a couple of weeks to years.

The AAFP has a large number of members working internationally as well an international membership category for family physicians from other countries. It has 1576 international members who represent 101 countries. Of these, 17.1% are from Canada and another 11.1% are from Central America and the Caribbean islands.

Although the AAFP is a US organization, membership interest has led to international support programs. The Center for International Health Initiatives has provided many informal consultations, largely to members who are working across national borders. It has also provided formal consultations for residency development in Macau, the Bahamas, Saudi Arabia, and India. The AAFP, as a subcontractor to the United States Agency for International Development, helped provide a national plan for integrating family medicine into the health care system and medical education in Albania. The AAFP sponsors a global health meeting each year and is an active member of Wonca.

Wonca is a global organization of family medicine organizations, but it has individual and academic memberships as well. Currently, it encompasses 120 member organizations representing 100 countries and at least 80% of the world population. Wonca has academic department memberships: there are currently 43 academic member organizations from 14 countries in addition to 1800 direct individual members. Wonca fosters the growth and development of family medicine throughout the world and interfaces with many global organizations and national GOs.

GLOBAL FAMILY MEDICINE
EDUCATION
Our international activities began 45 years ago when one of us, Dr Heffron, spent 2 years working in a 40-bed missionary hospital in central Puerto Rico. Life has been enriched by sabbatical leaves working in family medicine education in India, South America, Africa (Figure 1), and the Middle East, with about 6 short (2 weeks or longer) consulting trips a year. These consultations have involved starting new residencies in mission settings, then teaching and consulting longitudinally as the programs develop.

For the past 16 years, Dr Jenkins has led 8 to 12 family medicine education and faculty development conferences per year outside the United States. He spends 4 months a year overseas, and many family medicine educators and other specialists have participated in this effort.

We joined efforts about 10 years ago to provide residency consultations and educational conferences through missionary efforts related to the In His Image (IHI) Family Medicine Residency in Tulsa, Oklahoma. This is a fully accredited residency with a strong emphasis in training family medicine specialists to be global missionary family physicians. The residency currently has 34 graduates who devote their full time to meeting global health needs. IHI has an affiliated international network of several residencies largely led by graduates of the program. A sizeable number of other IHI graduates have been missionary doctors for intervals of several years and continue to serve as part-time missionaries while practicing in the United States.

Our passion is to consult with, help start, teach in, and foster development of family medicine residencies that train local physicians in the national educational, socioeconomic, and cultural milieu to meet the health care needs of their own country. We have found that it is much more efficient to train family physicians locally than to bring them to the United States, where the training may not be appropriate to the needs of their home country and the rate of return home is quite low.

We have also conducted continuing medical education, or continuing professional development (CPD), programs in multiple sites around the world, most of which have been in resource-poor countries. These have been in missionary as well as government and NGO secular settings. More than 100 teams have volunteered in over 15 countries working with dozens of local medical schools, post-graduate training programs, retraining programs, hospitals, ministries of health, and faith-based NGO family medicine residencies.

OPPORTUNITIES FOR
VOLUNTEERING
Hope Partnerships International (HPI). This NGO fosters the development of family medicine residencies largely in resource-poor countries. It has a closely related network of 7 residencies in 4 different “closed” countries that share curriculum, rotations, faculty development, consulting, and other educational programs among the network. This is a federation of loosely affiliated core residencies; each is sponsored by its own organization and directed by its own personnel. There are also some “cloud” residencies that have a looser affiliation but are able to share ideas, curriculum, and faculty development workshops.

The first program was started in Macau and has had 15 graduates. Some have gone into government training programs; others have stayed to teach in the residency or are delivering health care in Macau and on the mainland of China. The network residencies have from one to six residents, and the faculty range from one to seven.

The curriculum usually includes teaching in an ambulatory setting, inpatient rotations on at least all the basic specialties and some subspecialty areas, community experiences, and research (Figure 2). Some have only ambulatory training experiences and do not train the graduates for hospital work. These programs are scattered across Central Asia, China, India, and North Africa.

These residencies can use additional volunteer help. This can include family physicians and physicians of other specialties from academic or practice backgrounds. All the residencies require recognition and accreditation by their governments as specialty programs and long-term funding. These needs are almost universally present in all the other programs we describe.

Emmanuel Hospital Association (EHA). At one time there were about 500 missionary hospitals throughout India. These hospitals provided much needed health care to the Indian people. Over the past 30 years or so, the number of these hospitals has diminished.

The EHA was formed as a Christian India-based agency (NGO) and has subsequently taken over or reopened 23 of these hospitals and 34 community health centers. The EHA has started three family medicine residencies with a goal of training family physicians to work in their institutions. This is an active vibrant organization with solid leadership and a vision to improve family medicine education within their programs. They currently have 21 residents and 16 graduates. Staff physicians from multiple specialties teach in these programs.

A new development is underway in Nagaland, a state in India in the far northeastern part of the country inhabited by over 1 million people made up of 12 different tribes. At present the state has neither a medical school nor any postgraduate programs. The EHA is working with the government of Nagaland and the Christian Medical College in Vellore, India, to develop a family medicine residency (Figure 3). A hospital is also being constructed. After the family medicine residency is operational, there are plans to add other specialty teaching programs and eventually have it become a teaching hospital for a new medical school. This is an open opportunity for academic contributions by expatriate volunteers.

Albania. As a result of the extensive involvement of the AAFP, family medicine has now been recognized for several years in Albania and continues to develop. The national medical school has a department of family medicine with several graduating classes.

There is still a need for a stronger organization of family physicians, such as an Albanian Academy of Family Physicians could offer. A mandate requiring annual CPD was recently implemented. A local mission medical center has sponsored for 8 years a CPD educational program, which has also been recognized for approved hours to meet the national requirements. American volunteer physicians have formed a part of the faculty for this transformation conference (Figure 4).

The same team of faculty has traveled to Prishtina, Kosova, during the past 3 years to present a similar conference to the residents in the family medicine department at the medical school. The Kosova residency program is an interesting model in which the ambulatory portion of the residency training takes place in eight teaching centers scattered around the country. Local physicians become the faculty in these sites, and all residents return to the medical school one day a week for the academic portion of the program. Volunteers are needed to participate in these teaching exercises each year. In addition, a large number of ethnic Albanians in nearby Montenegro and Macedonia have medical educational needs that might be met by collaborative programs with Albania and Kosova.

Kabul, Afghanistan. Years of warfare and economic and social turmoil have seriously interfered with medical education in Afghanistan. The medical school was even closed down for several years, and the number of women entering medicine drastically diminished. This disrupted the delivery of health care, especially to women, throughout the country.
After the Taliban were ousted from power, the newly installed government and its international partners began the difficult task of rebuilding the country. In 2003 the Afghan Ministry of Public Health published the Basic Package of Health Services, a framework for the delivery of primary health care to the entire population; however, at the time there were no primary care training programs or specialists in the country.

To address the need for primary care specialists, Dr Tim Fader and others began the first family medicine training program in Afghanistan in 2004 at CURE International Hospital in Kabul. The Ministry of Public Health approved this 3-year program and continues to recognize graduates as specialists. While graduates of the family medicine program work in a variety of settings, the curriculum is designed specifically to prepare physicians to work in district hospitals, which are the hub of the primary care delivery system.

Currently, there are two family medicine training programs in Kabul, with a total of 22 residents in training. Fifteen physicians have graduated from the programs. Five graduates now work as instructors in family medicine in one residency program, and four in the other program (Figure 5). Volunteer specialists from the West are critical to the continued development of these training programs. Family medicine educators who speak Dari are especially welcome, and educators from multiple specialties can enhance the teaching program.

Aswan, Egypt. The Germania Hospital has been serving the people of Aswan for more than 100 years. It is a 75-bed hospital with general medical, surgical, pediatric, and obstetric services and laboratory and x-ray facilities. The hospital has ambulatory services on site and community clinic facilities in two villages nearby. This combination gives them excellent resources for a teaching program.

Dr Milad Hanna returned to his home in Aswan in 2008 with a dream of starting a family medicine residency in this hospital. Under his leadership, the hospital opened a residency with a first class of four residents in the spring of 2009. The residents in the program are highly committed, and several have career goals of meeting the needs of rural people in Egypt as well as the Nubian people to the south in Sudan, especially Darfur.

The hospital has specialists who can participate in teaching the curriculum of the various specialties, but there is a real need for additional family physicians to teach in the communities and the family medicine part of the curriculum. Non-Egyptians cannot stay for more than 1 month; thus, the greatest need is for Egyptian family physicians who can teach for longer periods.

Rwanda. Dr Cal Wilson has spearheaded a series of programs to introduce family medicine in Rwanda. When he first went there in 2007, there were no Rwandan family physicians. The health care system was either specialist-based or performed by physicians with no postgraduate training. The country was still recovering from genocide, and the economy was growing very slowly. The national medical school did not have a department of family medicine, and the medical education system was also specialty based. More than half of all graduates of the medical school had left the country, largely to relocate in the United Kingdom and the United States.

Dr Wilson undertook a study of how family physicians could help meet the health care needs of Rwanda. As a result of his research, a department of family medicine was created in the national school of medicine and a postgraduate program in family medicine was also started. Residencies are now operative in the teaching hospital and two district hospitals.

The pressing need is to recruit teachers to be program directors in the new residencies as well as to offer faculty development programs to family physicians to facilitate their teaching skills. Family physicians with some residency teaching experience who could stay for 1 to 5 years would be indispensable, although there could be a place for shorter-term teachers as well.

Ecuador. Dr Wilson again was the agent leading to a successful program at Hospital Vozandes in Quito, Ecuador. He started the residency program in 1985, and there have been a succession of graduates each year. These graduates have founded and been leaders in the Ecuador Academy of Family Physicians, and they have continued to provide services and education throughout the country. Dr Wilson turned over the leadership of the Vozandes program to its graduates after 10 years, and several have taught in the program and continued it. Graduates have started a department of family medicine in one of the medical schools in Quito. The residency also has part of the training in a rural hospital in the eastern jungle region of the country.

The government of Ecuador has started residencies of their own in government hospitals. Graduates of the Vozandes program have been faculty and directors of these residencies. As a missionary program, they developed additional curricular areas so that family medicine physicians could be sent to Spanish-speaking countries. Some of their first trainees have gone to Africa and have served on disaster relief missions.

There are American faculty in the residency and others who teach for short periods, some in the area of procedures. The Vozandes program has a continuing need for both long-term and short-term volunteer teachers.

Cameroon. The Mbingo Baptist Hospital is a 258-bed general medical and surgical hospital that was started in 1952. It is a part of a wider Cameroonian health system program of three hospitals that have a total of more than 500 beds. There are 20 associated health centers and 40 primary care posts with about 400,000 visits a year and some 28,000 admissions, in addition to community health education programs. The health system has a well-established surgical residency, and an internal medicine primary care program was recently started. 

The Banso Baptist Hospital is a part of this network, and they are currently exploring the possibility of starting a family medicine residency. The other basic specialties are present, and the greatest need at this time is to recruit a family medicine educator/practitioner to serve as program director for the new
residency.

FIND YOUR NICHE
Volunteer teaching can be a highly rewarding experience. There are needs in many other places in the world than those we have mentioned. Another advantage of these family medicine residencies is that almost any specialty can be useful. For example, a dermatologist with a thumb drive full of slides can become the dermatology curriculum for a group of residents. We encourage you to find your niche. ■