Thank you. Good morning. Yeah. Just big thanks to Dr. Kwame and SCCM for bringing us all together and thanks to all of you for attending a global health talk. And thanks to Steven for running our AV show over here. So yeah, I'm Anna Crawford. I'm at Stanford University. I'm trained in anesthesia and critical care and I direct our global engagement strategy in the Department of Anesthesia there. I've been asked to talk about professional development and exchange programs within global health. And so I want to talk about why we want to do that, why we want to bring global colleagues here and how to bring global colleagues here. So I'm going to ask the audience to participate a little bit here. What's the best way to learn and deliver better critical care? Is it A, have someone tell you about it, B, reading about it, or C, seeing it, simulating it, practicing it, and quality improvement? Who votes for A? How about B? Okay. How about C? You guys got the right answer. Perfect. So the WHO defines health as a state of complete physical, mental, and social well-being, not merely an absence of disease or infirmity. We've had this definition of health since 1946. And over the decades, we have had lots of well-intentioned individuals, institutions, all of our colleagues doing really great work to try to bring health across the globe. And this has largely been done with mission trips and outreach programs, but also disaster response and conflict and epidemic and pandemic responses and donations of both time, service, and education. And so a lot of these things are things that we're doing now at the SECM. But I want to kind of push our definition a little bit further around global health. And what we're really trying to do is achieve universal health coverage. And that means bringing the highest degree of health attainable by all people across the globe. And so in order to do this, we need to shift our thinking a little bit in global health and start to focus a little bit more on how we can build partnerships and how our efforts can be bidirectional. Kind of the days of good intentions and us helping them are over. We really need to be measuring our impact, and we really need to actually be listening and learning for the lessons that we can take away as well. There's a greater focus now on education and training and professional development, advocacy and policy, quality improvement, and research. And I think we all know that education and training is an amazing tool, but we're only as good as the systems in which we work. So we really need to be working, and Dr. Sampson made great examples of working along stakeholders, infrastructure, policy, advocacy, all of these things. This is a little bit of humor for you guys. So this is a group called RatiAid. They're out of Norway and they're hilarious, but they use their humor to make really, really important points for us. And some of it is how we think about global health and how we think about our efforts as we go and interact with others across the world. And they really help us to avoid some of these things that we've been guilty of, myself included, for many, many years. And that's a unidirectional mentality. It's preconceived notions of the problems and bringing our own solutions rather than listening to our colleagues abroad, and having this charity perspective only, and then making a lot of cultural assumptions. So I'm going to play you just 35 seconds of this video. I'm basically heading up a team that's getting Africans together in this time of need for Norway, you know, helping them out. A lot of people aren't aware of what's going on there right now. It's kind of just as bad as poverty, if you ask me. Sunlight puts smiles on people's faces. People don't ignore starving people, so why should we ignore cold people? Frostbite kills too. Africa, we need to make a difference in Norway. We need to collect our radiators, ship them over there, and spread some warmth, spread some light, and spread some smiles. Say yes to radiate. So they go on to create this entire, like, music video with all these African folks singing about, it's basically like we are the world. And I really, really love this because it really challenges us to think about our own motivations and involvement. It also forces us to think about how are we actually portraying our colleagues abroad. So a lot of the, there's actually been studies done, when you look at images that represent global health, it's usually a woman, a child, she's black or Asian, and she looks destitute. Just because our colleagues don't have resources doesn't mean that they're not capable and very talented physicians and providers. So I really love this campaign to get us to think a little bit more about that. And some of the things we've learned, I've learned over the years, and I've definitely been guilty of some of those same things, but we really need to understand the problem. Because if we make assumptions about the problem, we're going to bring our own solutions, and just as Dr. Sampson pointed out, a lot of times they're not going to work. So we need to understand the healthcare systems, the stakeholders. We also need to have a good lookout for cultural differences. Things that we think, like, oh, you just have to do it this way, and you just have to tell your administration this, or your hospital director that, cultures are different. Sometimes cultures are more hierarchical, and the things that we think should just be may not work in that culture. We also need to facilitate our colleagues. It's not us helping them or us coming with our own solutions. We really need to listen to their definition of their problem and their solutions, and we need to be the facilitators to help them achieve their own goals. And this happens a lot through these bidirectional partnerships, collaborations, and an academic exchange. We need to look for lessons. We don't know everything just because we're in a high-resourced setting. They are much more adept at innovation because they are resource-constrained. When they have supply chain disruptions, they don't lose their minds thinking, I don't have any rocuronium. They find another medication to give, right? They also are really, really good at green practices. The amount of waste that we generate in high-income countries is astronomical. When we leave the operating theater at Stanford, we'll have four to five huge bags of trash just from one surgery, one patient. In Rwanda, we have a kick bucket. So we have a lot to learn from our colleagues. We just need to open our eyes and ears and listen. This article is written by a good friend of mine, Farai Matsumoto. He was in Zimbabwe when I met him, but now he's in Botswana, and he goes back to prove the same point that John Sampson made. At the beginning of the pandemic, I think you probably all remember that the world flooded low- and middle-income countries with ventilators, and at that time only about 15% of patients actually needed advanced-level critical care. Additionally, there were no intensivists. There was no power. There was no oxygen. So we really need to stop imposing our own ideas and understand the problems so that we can facilitate our colleagues' solutions. This article is a little bit older, but I really, really love it, and it's probably in every single talk I've ever given, but this is about questioning your own motivations for becoming involved in global health, and Dr. Phil Pott categorizes these into three different categories, motivations I'd rather suppress. I want to do global health because it's sexy, because I get frequent flyer miles, because I get to travel. You might not want to tell people that. The second category is motivations that I can tolerate. I feel a sense of reward. I want to give back. Those are things that are tolerable for us to be involved in global health, but the things to which we really want to aspire is we are part of a global community. All of us are in this together. The pandemic certainly showed us that, right? And we need to do everything together to improve patient care across the entire globe because we're all in this together. So that's what I'd like to aspire to, improving patient outcomes. How do we do this? How do we bring our colleagues here? How do we create bidirectional partnerships and collaboration? Some of the pushback that I've gotten over the years is it's too expensive. I'm here to say it's no more expensive to send me or my residents or my co-faculty or my fellows to Rwanda. It's no more expensive than it is to bring them to us. And going back to the first question I asked you, is it better for us to go there and tell them how to do it or how we do it? Is it better for them to read it in a book? No. When you see the resources in a functional healthcare system that you've read about in books, it's eye-opening, right? So this is really what we want to develop in our colleagues. There are a lot of considerations. You have to determine if your visiting observers are going to be able to actually do patient care. In the United States, we make this exceedingly difficult as most of you know. There are lots of us working on this. So there's work being done at the federal level for visas and then also work done at the state level so we can get people licensed under a supervised license or otherwise so that they can actually touch patients and take care of them. But for now, a lot of these programs are just visiting observers is what we call them at Stanford. I mentioned the visa and funding. Funding is a big issue. I hope that you can think just for a second, why spend the money on sending us there if we can spend the money bringing a bunch of them here so that we can actually share information about the resources. There's a lot of considerations around paying them. So there's a lot of rules around the type of visa that they're on, but also you want to make sure that you do not impose a tax liability on your guests. It's kind of rude. Travel, lodging, meals, these are obvious things you're going to have to consider, but also vaccinations and having your colleagues cleared through occupational health can also be quite a challenge. Some of my colleagues don't have access to the same vaccines that we have in the United States, and so they may actually have to spend, you know, one, two, three, four days waiting to get their titers back from whatever vaccine they received in our occupational health office. You want to ensure that they are compliant with privacy and HIPAA. You also need help. If they're going to be here for a few days, where are they going to go on each day? Who's going to take them around? So the scheduling and logistics requires a bit of effort. And then you want to make sure if they get sick, and trust me, I've had some really interesting situations with my colleagues coming here, including pregnancy and malaria, but you want to make sure that your colleagues are covered with insurance and evacuation for worst case scenarios. Again, cultural competence. When you're setting all this up, you really need to think about the environment from which your colleagues are coming, language barriers, whether or not to be assertive. So you think that your colleague is going to come and be really assertive and say, I want to learn this and talk to all the people in the hospital, but they may be shy or that might not be a cultural norm for them. And then communications. They don't have the same continuous access to the internet that we're all addicted to. So be sure that you can have good communication with them. And then we like to send our friends to the American Society of Anesthesiology Conference, but maybe I'll start sending them here to the SCCM. So these are all things to consider when planning to bring a colleague here. So we've been running these programs since 2015. We've had four cohorts come through. We had three pre-pandemic and then we just restarted the program, which made my heart sing. And you can see, we have people from mostly Africa, Asia, and then Central America. There have been numerous publications, presentations, grand rounds, deliveries, all of this for colleagues that would otherwise not have these professional development opportunities. So this is, this is where I put most of my energy is in this professional equity and exchange program. Professional societies have a huge role to play. I am so impressed with the amount of global health that has been featured in this conference. Thank you Kwame. Because I think it really is great as a professional society to reach out and collaborate in other countries. So certainly Stanford is not the only program doing this. The American Society of Anesthesiologists does this. The World Federation Societies of Anesthesiologists does this. And actually ACGME is now expanding their global services. So they're helping other countries when they're trying to develop residency training programs, fellowships, et cetera, how to set up accreditation processes. So this is really expanding quite a bit, which makes me really happy. You guys know the amazing work that's being done here at the SCCM and it continues to grow. And most of the people who do a lot of this are in this room and on this stage. One thing I do want to bring to your attention is at the World Health Assembly this past year we were really excited that the resolution was passed for health system strengthening for emergency critical and operative care or the ECHO resolution, which is now in its implementation stages. So the SCCM is working with the acute care network and the WHO to be part of that and basically bringing critical care across the globe. So hopefully I've convinced you that you need to bring people here and create bilateral, bi-directional partnerships rather than us just traveling around the world in our capes. And hopefully I gave you a little bit of information on how to do that. I'm available to any of you who have questions about that and would be happy to share any of our experiences about developing these types of programs. Thank you very much.

bidirectional partnerships

global health

professional development

universal health coverage

cultural differences