Overview

The purpose of resident clinical experience in global health is to provide focused, individualized education in the areas of global health, population health and/or advocacy within a broader pediatrics clinical training. Past residents have traveled to countries all over the globe, including several sites in Africa, Asia, South America, and Europe. In recent years, the Department has encouraged residents to consider clinical rotations in two countries, Malawi and Nicaragua. A description of the resources in these sites follows.

Malawi

UNCPM sponsors physicians who have supported pediatric inpatient clinical care and research at Kamuzu Central Hospital (KCH) since 2009. In 2016, UNC Pediatrics became part of the PACHIMAKE consortium, (Pediatric Alliance for Child Health Improvement in Malawi at KCH and Environs, a consortium of US-based and Malawian institutions dedicated to working together to improve the outcomes of acutely-ill children admitted to KCH through focused educational, clinical, and research initiatives.

Kamuzu Central Hospital is the national referral hospital in the capital city of Lilongwe, serving the central region of Malawi. It is an 800-bed hospital, with approximately 300 pediatric beds. The pediatric ward admits more than 27,000 patients per year and manages all medical emergencies for the region. KCH is overseen by the Ministry of Health and is affiliated with the Malawi College of Medicine with on-site facilities for the third-year Malawian medical students. They hope to begin a pediatric residency soon. UNC Pediatric residents rotate through the clinical areas of the hospital and are offered the opportunity to work alongside Malawian physicians in general pediatrics in addition to sub-specialties including Emergency care, Cardiology, Oncology, and Sickle Cell clinics. UNC developed a sickle-cell clinic at KCH in 2013, has helped establish and maintain Malawian residency programs in Surgery and Obstetrics and Gynecology, and maintains a robust relationship with these departments.

The UNC pediatric residency program has been sending residents for short-term rotations since 2002 and supported three, month-long rotations and the fellowship research of a Pediatric Emergency Medicine fellow from 2013 to 2016. In the past two years the program has grown, and in 2017-18, UNC sent two medical students and six pediatric residents to KCH, each of whom completed at least a month-long rotation. Three pediatric fellows are currently involved in research and clinical activities at KCH. Housing is provided by UNC PM on the grounds of KCH, and coordination of transportation and licensing is provided by UNC Project Malawi.

The in-country Pediatric Director of UNC Project Malawi is Dr. Tisu Mvalo, and the US Director is Dr. Elizabeth Fitzgerald. On-the-ground mentorship for residents is provided by Drs. Mvalo and Fitzgerald or one of the rotating PACHIMAKE Pediatric Emergency Medicine (PEM)-trained physicians, to augment the teaching and supervision provided by the Malawian staff.

UNC Project Malawi (UNCPM)

UNC Project Malawi (UNCPM) is a collaboration between UNC and the Malawi Ministry of Health that was established in 1999. UNCPM employs 375 Malawian staff, including clinicians, nurses, laboratory staff, pharmacy technicians, data officers, and administrative staff. In addition, UNCPM has 15 permanent Malawian and expatriate resident faculty in infectious diseases, hematology-oncology, women’s health, pediatrics, and epidemiology. UNCPM serves as a training site of the Fogarty International Center, and as the site of many ongoing research studies, including protocols implemented by the NIH. Several international protocols have been chaired by UNC faculty. Most studies are led locally by Malawian doctors whose postgraduate training UNC has supported, including Malawian Pediatrician Dr. Tisu Mvalo. Annually, UNCPM receives ~500,000 USD for infrastructure support from UNC, ~11 million USD in grants for clinical research and training, and ~5 million USD in grants for implementation and service delivery. Much of this support comes from the NIH; other support comes from the Bill & Melinda Gates Foundation and private donors. Currently, UNC PM leadership is housed in the UNC Institute of Global Health and Infectious Disease (IGHID). Historically, UNCPM research has focused on communicable diseases. With the arrival of new faculty, there has been substantial growth and diversification, including major activities in cancer, surgery, women’s health, pediatrics, and sickle cell disease.

Nicaragua

In 2014, as part of the larger UNC Program in Nicaragua, the Department of Pediatrics entered into a formal educational exchange program with the University of Nicaragua at León (UNAN- León).  Both institutions, through a formal Memorandum of Understanding, formed the UNC-UNAN León Global Health Partnership and are committed to an exchange of faculty and learners. Over the past five years, education has served as a bridge between the two institutions and facilitated mutual growth, fostering additional collaboration in patient care and research.

Residents are able to travel to León to participate in clinical work. They work alongside UNAN-León residents and faculty in both inpatient and outpatient settings until the mid-afternoon. Afterward, they participate in one-on-one Spanish lessons. The hospital is a traditional, academic teaching hospital that serves as a referral hospital for the region. As a public institution, there are limited resources to serve complex patients at a high volume. Our residents rotate on subspecialty ward services such as infectious diseases and pulmonology, and they can work in the emergency department, as well as more remote community health posts. There are also opportunities to engage in research and quality improvement projects. Logistics and expectations of the rotation are well-defined, though flexibility exists to personalize each resident’s educational experience.

Faculty Contact: Richard Hobbs, MD, FAAP, FACP Richard.Hobbs@unchealth.unc.edu

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A hallmark of the Nicaraguan program has been the exchange of medical faculty between UNC and UNAN-León. The Department has hosted a Nicaraguan faculty member annually since 2015 and has sent Pediatric subspecialists to Nicaragua to provide CME lectures on subjects including Endocrinology, Primary Care, and Neonatology. As a result of this exchange, UNC has two adjunct professors in León, Dr. Gladys Jarqin and Dr. Augusto Fuentes.

Since 2016, UNC Cardiology (adult and pediatric) has partnered with Project Health for León to see patients with congenital and acquired heart defects (many with rheumatic heart disease). Twice yearly, UNC teams travel to León to evaluate patients and perform life-saving procedures. Drs. Hobbs and Frantz recently gathered a team that included UNC ultrasonographers, pediatric residents, and internal medicine faculty. On that trip, Dr. Frantz did first-in-León ASD and PDA closures with catheter-based procedures, whereas previously open heart surgery was the only option. This UNC/PHL program now has an affiliated medical student elective for credit and we recently cultivated a $100,000 donation to continue UNC’s much needed clinical work for both adult and pediatric cardiology.

Pediatric Global Health Simulation

Pre-departure preparation resources for UNC pediatric resident rotations in global health also includes a biannual Pediatric Global Health Simulation Curriculum, developed and implemented by Dr. Fitzgerald, Dr. Alyssa Tilly (UNC Palliative Care fellow) and Dr. Emily Ciccone (UNC ID fellow).

This curriculum was developed to acquaint residents and students interested in global health to frequently encountered disease processes in children, their management, and procedures performed in low-resource settings. The modules include Emergency Triage Assessment and Treatment (ETAT), respiratory distress, malnutrition, and undifferentiated shock. Procedures taught include the use of point-of-care ultrasound to help identify the cause of shock and the building of bubble CPAP. Drs. Tilly and Ciccone also developed a pre-departure checklist for resident travelers preparing for Global Health electives. Dr. Fitzgerald helps prepare residents for travel and debriefs with them upon return. Residents are expected to present a morning report to their colleagues about their experience.