Dianna Louie and Shafik Dharamsi discuss the role of health workers as health advocates and use Dianna’s experiences in Uganda to illustrate their points

“We are the first generation in history that can end extreme poverty.
That’s our good fortune, our challenge and our responsibility.” Jeffrey Sachs

Many students spend the summer between first and second year conducting medical research in order to improve their resume for entry into postgraduate medical training. Others shadow different specialists in an attempt to figure out what type of medicine they want to practice at the end of their four year program.

I decided to do something different.

This Article highlights my experience during the summer of 2007 in a rural village in Uganda. Under the guidance of my professor, Dr. Dharamsi, at the University of British Columbia (UBC) Department of Family Practice, I sought to develop my capacity in international/global health and my role as Health Advocate.

The Physician’s Role as Health Advocate
The Royal College of Physicians and Surgeons of Canada implemented a framework for medical education called the CanMEDS framework of essential physician competencies. (1) It is a framework that is organized around seven physician Roles: Medical Expert, defined as the central role, and surrounded by the role of physician as Communicator, Collaborator, Health Advocate, Manager, Scholar and Professional. The Health Advocate role requires physicians to respond to the needs of “vulnerable or marginalized populations.” It stipulates that physicians have a “duty to improve the overall health of their patients and the society they serve… to assist them in navigating the health care system and accessing the appropriate health resources in a timely manner… [and] to identify and collaboratively address broad health issues and the determinants of health.” Health advocacy is seen also as “an essential and fundamental component of health promotion…appropriately expressed both by individual and collective actions of physicians in influencing public health and policy.” The aim is to cultivate in medical students a greater awareness of the social determinants of health, and to develop in future physicians a strong sense of social accountability and responsibility. (2)

The Health Advocate role is difficult to teach within the confines of the traditional classroom. Lectures and small group discussions can provide a sound theoretical base; however, for skill development, an experiential learning environment is necessary to help students move from rhetoric to action.

Medical education facilitates opportunities to foster most of the CanMEDS roles: through clinical skills and family practice we learn the essential skills to communicate with our patients and our peers; Problem Based learning (PBL) and clinical rotations foster opportunities for students to learn the importance and value of collaborations, management, and the development of scholarship/research skills; and professionalism is a thread that runs through all aspects of the medical program. What seems to be lacking, however, is an opportunity to develop our roles as Health Advocates.

Then again, it seems like a challenging concept to teach within a lecture setting. Many students are unclear about the responsibilities that fall under the Advocate role. I never fully understood my responsibilities as a medical student and a future health care professional about my role as a health advocate. Fortunately, the Doctor, Patient & Society course at UBC in second year medicine provides students with the opportunity to work with a faculty member to explore and create community service learning opportunities as pedagogy to foster the development of social responsibility.

Doctor, Patient & Society (DPAS)
Doctor, Patient and Society is a multidisciplinary course that enables medical students to examine critical issues in health care. Through lectures and small group seminars we address issues affecting the patient-doctor relationship, health care systems, research, epidemiology, prevention, ethics, behavioural and social sciences, resource allocation, multiculturalism, and marginalized populations. Most of the time is spent working in small problem-based tutorial groups to explore the significance of these issues to us as future physicians. Through DPAS, Dr. Dharamsi and I piloted an international service learning project designed to help me learn the value and importance of the physician’s role as Health Advocate.

Dianna’s Experience
I was based at the Tekera Resource Centre (TRC) in Masaka, Uganda for 8 weeks. The Centre includes a health clinic and counselling service, a primary school, adult education classes, a community work programme and a community farm for about 15, 000 people living in Tekera and surrounding settlements. I had two primary objectives: to volunteer my time at the Centre, and to reflect on my role as a Health Advocate.

The importance of critical reflection
Volunteering is not a new experience for me. I have volunteered both locally and internationally. While volunteering within my own community has always been rewarding, I have also benefited immensely from volunteering in international settings in areas where there is extreme poverty and a critical shortage of health professionals. What was different for me this time is that I kept a reflective journal to record my experiences, thoughts, feelings and concerns. At first I felt that keeping a journal would be a burden. I soon realized that journaling during service-learning is the key to learning. I used the critical incident technique to explore how various events and experiences influenced my professional and personal growth. (3) Reflective journaling enabled me to examine critically what it means to be a doctor. I learned how cultural views impact perceptions of health and illness, the struggles of poverty, and observed firsthand the necessity for health promotion. I learned more than I ever could have from lectures or from a textbook. I now have such a deeper appreciation for volunteering and the opportunities it provides.

Reflections on social responsibility
UBC aspires to graduate students who will become outstanding global citizens, with a strong sense of social responsibility, who value diversity, and who will work with and for their communities. Service-learning is a promising pedagogy for achieving these aspirations. Volunteerism, particularly in a community-based setting in an under-resourced country, coupled with reflective journaling, is an invaluable learning experience.

My interactions and reflections revealed that social responsibility is rarely innate. It is indeed fostered and redefined by experience. I always believed that being socially responsible meant donating to charity, but my volunteer experiences working with vulnerable communities taught me that social responsibility is about building strong relationships, witnessing and giving voice to those who are stifled by the social burdens that seem impossible to overcome because of poverty and vulnerability. It is not about creating a dependency relationship. It is about developing relationships based on mutual respect, care and compassion. It involves working with and for communities; being a facilitator toward achieving what communities feel is best for them. However, many well intentioned individuals and organizations tend to engage with communities using a top-down approach-deciding what is best instead of asking communities what they determine to be best for them. I learned that communities have a keen sense of what is important. I learned that ownership, building trust and partnership is important for successful and sustainable development.

At the TRC, I witnessed the resilience and determination the local people had for problem-solving with limited resources. I marvelled at how much capacity there was among people who had very little. For example, women in the community were all growing vegetables to feed their families. They found that their yield often exceeded their ability to preserve or sell the food within the village. They mobilized themselves and asked if TRC could take their excess vegetables into town once a week and sell them at the market. With the help of TRC they created a ‘farmers co-op’ and now supply the major hotels in the closest town (Masaka) and are able to sell their produce for a significant sum.

I left TRC feeling like I’ve taken more than I was able to give. Through my interactions with local villagers, patients and health care providers, I learned about social responsibility and global citizenship.

Learning about the Social Determinants of Health
In DPAS we had a number of lectures on the social determinants of health. These lectures identified that the social and economic conditions in which people live determine their level of health. Therefore someone without the opportunity of education or without access to clean water was much more likely to contract disease than someone who has these necessities. Although conceptually this makes sense, it was not until I actually lived in areas of extreme poverty that I began to develop a deeper understanding of the impact of non-biological determinants of health. I witnessed how lack of access to education, clean water, mosquito nets, and basic health care impacts people’s lives. I witnessed a 3 year-old girl die from malaria. A mosquito net costing less than $5 could have saved her.

By working in such a resource-poor setting I learned what the village really wanted and felt they needed - which practically speaking were many of the medical as well as non-medical determinants of health like education for their children, an understanding of hygiene, clean water, how to decrease infant mortality and how to optimize their crops, especially during longer droughts. Although we can read about these issues in texts books, it appears that the information is only received as numbers and figures, not as challenges faced daily by human beings. After working with the women’s group weekly, an issue concern regarding simple public health kept coming up. The women were interested in learning about what caused disease and why when one person was sick, others around them often became ill as well. As a Health Advocate, I thought this was the perfect opportunity to work with the women and locals in the community. I worked with the local nurse at Tekera to create a curriculum that could be taught for one hour each week during “craft day” (a day when all the women get together and make crafts at the community centre). The curriculum included simple preventative health measures like hand washing, latrine building, and sexual health. This course was created to run for 8 weeks and then the women were given the opportunity to put forward further questions or concerns that they had. These were then emailed to me and a new curriculum was created and sent back to Uganda. I found this was an excellent way to address their concerns and interact with the women. The nurse is continuing these sessions with the work book I have left, as well as books that I have sent out for them to work from

From working on the ground the necessity of international service learning became clear. This method of learning is so vital because it is hands-on and interactive. It introduces an element that makes learning so much more memorable, influential and educational. International service learning challenges students to be community and socially responsive. It enables students to develop and apply knowledge outside the confines of the classroom, in the real world where lived experiences serve as foundations for learning. In medical school we are given so many opportunities to learn about the experience of our patients and learn from the experience of others; however there is rarely time to actually experience and reflect on what it means to be a doctor.

International service learning facilitates educational, emotional and introspective learning. As a student I was able to learn a lot about myself, my beliefs, and the type of doctor I want to be. Through working in rural Africa I also learned to understand the necessity of the basics of medicine like taking a through history and physical exam. With no access to labs, imaging, or any technology that requires electricity, diagnosis and treatment was based on knowing the patients, listening to their concerns, and identifying signs and symptoms. Although this took longer, it proved very effective despite the limitations I was faced with. This cemented for me the necessity and value of primary care.

This summer I am returning to Uganda. I plan to continue my work and research to further define the role each medical student has as a Health Advocate. This time, I will be accompanied another student, and we will partner with a medical student from Makerere Medical School. We look forward to another opportunity to work with vulnerable communities, to explore our roles and responsibilities as future doctors, to experience the essentials of primary care. As Dr. Dharamsi so aptly puts it: “To have learned means to never be able to go back to seeing and being in the world in the same way.”

Dianna Louie
2^nd Year Medical Student
University of British Columbia
Canada
dianna.louie@gmail.com

Shafik Dharamsi
Professor
Department of Family Practice
University of Columbia
Canada

For more information on the Tekera resource centre go to www.ugandavillage.org

(1) Frank JR. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada. http://meds.queensu.ca/medicine/obgyn/pdf/CanMEDS2005.booklet.pdf

(2) The Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 Framework. Pgs. 6-7. http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf

(3) Flanagan JC. The critical incident technique. Psycholog Bull 1954;51:327-58.

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This entry was posted on Monday, April 14th, 2008 at 6:38 pm and is filed under Medical Education, Perspectives, Africa, Articles. You can follow any responses to this entry through the RSS 2.0 feed. You can trackback from your own site.