With a record 65.6 million people displaced from their homes around the world — 22.5 million of them classified as refugees who have fled across borders — alarms are sounding about the health risks in overcrowded refugee settlements. Sanitation is soon overwhelmed, hygienic conditions rapidly deteriorate and malnutrition rises, contributing to the spread of contagious infections and neglected chronic diseases. Visiting medical teams come and go but health hazards remain.
Vanessa Kerry, the Boston physician who founded Seed Global Health and built an expanded Global Health Service Partnership, is campaigning for some new thinking about refugee health, and the people there who could be providing more care. She proposes that qualified but idle health care workers among the displaced people — doctors, nurses, midwives and others with specialist skills — be allowed to practice within refugee camps.
In an interview with PassBlue from Boston, where she is associate director of partnerships and global initiatives at Massachusetts General Hospital’s Department of Global Health, she said that she was also looking at the possibility of creating a program that would open careers in new host countries for refugee medical workers willing to accept jobs, especially teaching positions, in places in the developing world where health services are weak.
In an opinion article in April of this year for Devex, a website for the exchange of information on international development, humanitarian aid and global health, Kerry, who is already running innovative training programs in Africa, wrote:
“The World Health Organization data tell us that the global health workforce is experiencing a shortage of 7.2 million doctors, nurses and midwives — a shortage that will increase to 18 million by 2030 unless urgent action is taking. In many parts of the world, the shortage of faculty and a faltering pipeline of new trainees is contributing to this gap.”
Kerry’s nongovernmental organization, Seed Global Health, formed the Global Health Service Partnership in 2012 with the United States Peace Corps and the President’s [George W. Bush’s] Emergency Plan for AIDS Relief, (Pepfar), after introducing a long-term formula for improving health care in underserved communities. That program is now operating in 32 sites in five African countries: Liberia, Malawi, Swaziland, Tanzania and Uganda.
The keyword is continuity: the volunteers are there to train current local health professionals who in turn will train future generations to come, Kerry said.
In Africa, the Global Health Service Partnership assigns selected Peace Corps volunteers with professional health care credentials to a minimum of one year’s work — and life — in a community or local medical school. They not only teach health care workers about current medical practices but also try to impart some rethinking of how to make patient environments more compassionate and effective.
Many nongovernmental humanitarian organizations do great work in places where health care is substandard, including in refugee settings or areas affected by natural disasters or conflict. Many organizations also have to react with immediacy, and do not have the time to build long-term solutions.
“There’s a huge amount of interest and engagement in global health on this side,” Kerry said in the interview. “The world is resource heavy here, geographically, [but] it wasn’t necessarily being channeled into structured programs with that energy to really build upon itself year after year after year. It seemed there had to be a way to bring that all together.
“We took that approach to the refugee problem,” Kerry said. “You’ve got a huge number of displaced health care professionals looking for stability and a home and some sort of routine and a structure for their families, for themselves, to escape the purgatory of being a refugee.”
Both proposed programs — finding ways to put the skills of medically trained refugees to work in camps and resettling medical practitioners in professional positions in countries with great needs — are only in the exploratory stages. International rules and procedures, like issuing visas, need the commitment of governments and international agencies. In addition, refugees from more medically advanced countries, such as Syria, might not be willing to move to poor countries where conditions may not meet their standards and cultures may be radically different.
But there are glimmers of hope. The government of a Middle Eastern country housing a large number of refugees (Kerry didn’t want to name the country while negotiations are going on) has approached her to discuss employing refugees to train local medical people to work in camps. In Africa, the Ugandan government is open to finding ways to add refugee doctors to its medical faculties if the paperwork can be completed successfully and funds can be found to support the project.
“We’re still struggling, I think, because there are some barriers that we’ve learned about that might make it difficult, but it’s certainly a path worth pursuing because for us it’s a win-win,” Kerry said. “If you can provide a safe haven and a job and stability for a refugee health professional and then they can put their skills to work to provide services to that population in a culturally contextual way, it seems like an incredible opportunity. And so we feel very committed to ask, how can we make that happen?”
The support of governments is important for Kerry, the daughter of John Kerry, the former US senator and later secretary of state in the Obama administration.
“I’m a huge believer of engaging governments,” she said. “It allows you to get to scale faster, and it certainly is important in terms of creating collaborations and building a path forward for us and for others’ work.”
During and after the Ebola crisis, which severely affected Liberia, one of her partner countries, Kerry said she raised the issue of what comes next:
“How do you ask governments to be sure that they’re planning for the long-term takeover of the crisis response? What you don’t want is all this influx of resources — people and temporary services — that then get taken away.” She added that governments are important to that discussion because they are often left responsible for services. “Not every government works,” she said.
Of her established work in Africa, Kerry said: “The way that the main model works is that we have a flagship program with the US Peace Corps where we have recruited US health professionals, doctors and nurses and midwives, who serve as one-year Peace Corps volunteers. They embed in their communities. If they serve as faculty they report to their department chairs. We’ve been doing this now for four years, so we have trained over 13,000 health professionals in the last four years alone, and we are returning to the same sites year after year after year, so we are building a generational team of trainees.”
“We also provide clinical education,” she said. “That means we’re not just teaching in a classroom, but we’re showing what it means to take that knowledge and actually apply it to patient care, and transform what it looks like to give care, because historically nobody’s been doing that. These countries have ministries of health and ministries of education. Ministries of health support people who work in hospitals, and ministries of education support people to work in training institutions, but they are not supported to teach in hospitals. Clinical education is what’s falling through the cracks.”
Encouraging overworked and underappreciated hospital personnel to increase their self-confidence and act on their own initiative when they see a problem to be solved is part of the goal.
“We had a [volunteer] nurse working in northern Malawi, and she identified that patients were being treated in trauma and surgical wards without any pain medication,” Kerry said. “Patients’ dressings were not being changed.”
A cooperative effort of education and training led to the restructuring of how patients should be given appropriate care and how narcotic medications should be administered.
“The model for us has been about partnering with local institutions, local providers, to think about ways that we can advance the traditional experience, change patient outcomes and [improve] standards of care.”
Kerry said that one of her favorite stories is about the introduction of a machine to test blood counts in a hospital where Peace Corps volunteer was working with a young local nurse.
“They had one patient who had a hemoglobin count of 4. Yours or mine should be 10 to 12. This young nurse realized 4 was very low and reported that the blood bank was closed for the day and refused to provide any blood for this patient. The nurse realized that the patient would die without a transfusion. The volunteer health professional asked the nurse what she was going to do about that, and the young nurse went down to the blood and persuaded someone to provide the blood after hours. The patient, a young mother, survived. The young nurse realized through that interaction she could play a role as a patient advocate and powerful caregiver,” Kerry said.
“Where 90 percent of health care around the world is being provided by nonphysicians, but by nurses, their ability to have a voice that is heard, that is respected, and to be leaders in their communities, is critically important,” she added.
Not long before her interview with PassBlue, Kerry attended a Women Leaders in Global Health conference in Stanford, Calif. “What was very important as a gathering was really trying to point out the importance of women to the health care workforce and bring together a unified voice that can be heard in ways that we can help. The profession is dominated by women but at the same time it is still true, unfortunately, that to this day that there is a credibility gap between women and men.
“It was exciting to see the degree of energy in that room — women from all around the world, from all different professions,” she said, adding that the energy generated galvanized the room.
“Health is really critical to all we do in life,” Kerry said. “It relates to economic growth. It relates to political security. It relates to personal well-being and the opportunities how to thrive and survive, and I think that that’s what we need to embrace and realize. Investing in health is all about investing in principle to close the two standards of care and of opportunity in the world.”