College of Medicine MD Curriculum

Global Electives

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For 4th Year Medical Students:
Global Health 756 Electives | Global Health 755 Electives

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Traditional, month-long Global Health 756 electives:

The student’s clinical experience will be held in one of the locations (listed below) in which our Global Health Department has established formal affiliation agreements. Please note that Global Health elective rotations follow the UT COM 4th Year Clerkship Calendar dates; participation, however, is based on the affiliate partners’ availability. All original Global Health inquiries should be made at least 6 months in advance to secure participation. Additionally, participation is limited to 4 students per location per 4-week clerkship dates. This being the case, early requests for participation are recommended.

Students will be expected to manage a variety of problems; specifically the student will learn to integrate the knowledge of clinical disease entities, both medical and surgical. These disease entities will include, but are not limited to; trauma and acute surgical disease, oncology, cardiology/acute coronary disease, pulmonary disease/acute infectious disease entities, acute neurology emergencies, gastrointestinal disorders, endocrinology and renal/urologic disorders.

• Upon successful completion (via MedEd evaluation) students will receive 6 clinical med away elective hours for the rotation.

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Recurring Medical Missions (approved by the Global Health Committee as 2 or 4-week Global Health 755 electives):

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Guatemala

1. Guatemalan Rural Health Care System/Obstetrics & Gynecology Medical Mission with Dr. Anne Ruch: recurring yearly; month-long in both October and February

Dr. Ruch’s elective description: Petén is the largest and northernmost department of Guatemala. It accounts for approximately one third of the geographical area of Guatemala, but roughly 3.4% of the population. The department is bordered by Belize to the East and Mexico to the North and West. This region is best known for its Mayan ruins, which attract thousands of visitors from the US yearly. The Petén was first settled by the ancient Mayans as early as the 4th century BC. Students are encouraged to explore the cultural heritage and archeological sites in Guatemala to embrace this country' s rich and varied history.

Cervical cancer is an important public health problem in Guatemala. While the incidence and mortality rates of cervical cancer have declined significantly in developed countries where a large proportion of women are screened, there has been no such trend in developing countries. This is due to lack of awareness, nonexistent or poorly executed prevention programs, absence of governmental guidelines and lack of accurate cancer registries. In Guatemala, a majority of cervical cancer cases are diagnosed at an advanced stage of disease offering a poor prognosis. The barriers to combating cervical cancer in Guatemala are great. Governmental health care delivery is under the Ministry of Health (MOH). Theoretically, low-cost services are offered to the population through the local Areas de Salud in the department capitals and the Centros de Salud at the municipal level. The current government sponsored pap-smear program is fraught With problems including poor quality, insufficient staffing and infrastructure, delays in getting test results, sporadic availability of supplies, and many sociocultural barriers to obtaining the test. Thus, alternative methods for screening have been sought such as VIAA (Visual Inspection with Acetic Acid), HPV vaccine administration, VIAA with magnification and HPV screening alone.

This elective clerkship will enable fourth year medical students to gain four weeks of clinical and public health experience in the Petén region of Guatemala. Students will participate in a study to determine the appropriate approach for developing a program for cervical cancer prevention in this region. To accomplish this, a mass screening campaign is planned within the clinic in Santa Ana. A minimum of 1000 women will be screened both by conventional pap smear testing and by VIAA (visual inspection with acetic acid). American cytotechnologists from Promedica will interpret the pap smears so that confirmatory biopsies and treatment can be performed.

Additionally, women will be tested for HPV, and subtyping will be performed for positive results. At the clinics, students will be supervised by Dr. Ruch. They will have the opportunity to work with local health promoters as well.

Students will clinically participate by performing pap smears and HPV swabs, working with cytotechnologists to stain and read slides, and observing Guatemalan health promoters performing VIAA. Students will work with Guatemalan nurses to obtain focused health histories, including assessing for potential exposures and risk factors. Additionally, students will perform health outreach and complete health education projects in the communities. The project is collaborating with the National Institute of Health for further analysis of biopsy specimen, including evaluating for the presence of potential carcinogens from wood smoke. This project is expected to have a substantial impact on cervical cancer screening throughout Guatemala. Students will not only gain clinical experience, but will also develop an understanding of public health policy in underserved populations. Students will also work with Dr. Ruch during a week of gynecological surgeries. They will assist in surgeries as needed and will help prepare the patients preoperatively and care for them post-operatively.

• Upon successful completion (via MedEd evaluation) students will receive 6 clinical med away elective hours/credit for 4-week away elective for participation in the mission.

2. San Lucas Tolimán Guatemala with Dr. Richard Paat: recurring yearly; 8- 10 days in late July  

Dr. Paat’s Course Description: Students will be given an opportunity to travel with other health care professionals to a foreign country and deliver care to those in need.  The specialty of medicine will be dependent on the attending physician. Students will gain experience in developing a differential diagnosis and treatment plans for patients with various medical and surgical problems. 

Dr. Paat’s Team Letter: San Lucas Tolimán is a town with approximately 15,000 occupants that sits on the shores of the Lago de Atitlán. The history of the town dates back to the 15^th century when Mayans migrated to the area from more the north. Gradually, the town was taken over by the Spanish conquistadors after they arrived in Guatemala in the 16^th century. Today the town serves as a central hub of commerce, education, healthcare, and festivals for the surrounding 22 villages whose combined populations total about 20,000. The population of San Lucas is approximately 85% Mayan and therefore visitors can observe aspects of the traditional Mayan way of life[i].

The most prominent geographic feature is certainly the 90 square mile Lago de Atitlán. The lake is a source of employment for local fisherman, a source of drinking water for the town and local villages, and has also become a tourist destination attracting visitors from Guatemala and throughout the world[ii]. The land surrounding the town is mostly agricultural. Approximately 4000 families farm individual three-acre plots. Fields of coffee plants are seen on the mountainsides surrounding the town and the local Catholic Mission provides living wages to the growers in its collective. Due to the predominantly Mayan population, Townspeople are seen in traditional Mayan garb and the textiles, produced by hand using Mayan weaving techniques, are a common sight[iii].

The life expectancy in Guatemala is 141st in the world, with the average adult expected to live 71.2 years. This compares to the United States, which ranks 50th in the world for life expectancy, where the average life expectancy is 78.5 years. There are an estimated 0.9 physicians and 0.6 hospital beds in Guatemala for every 1,000 citizens. The country spends an average of $337 per capita annually on health care[iv], which places it as the country with the lowest healthcare expenditure in the Americas[v]. This perhaps accounts for their ranking of 79th in the world for infant mortality (25 per 1000) and 65th in the world for maternal mortality (110 per 100,000). Nearly 18% of the populations under 5 years old is under weight and there is a high rate of vector-borne and water-borne illness including hepatitis A, typhoid fever, dengue fever, and malaria[vi].

It is estimated that 20% of Guatemalans lack regular access to healthcare. Experts attribute poor access to a variety of entrenched social and political causes including insufficient taxation, a high concentration of wealth, and poor implementation of social policies. Forty percent of children have been found to be chronically malnourished and approximately 30% of pregnant women lack appropriate nutrition. The percentages for malnourishment go up when indigenous Guatemalans, considered to be 40% of the population, are analyzed separately[vii].

Guatemala has made strides in some areas, though there are others where more work is needed. A national vaccination program now provides a series of ten vaccines for 92% of infants throughout the country. Efforts are currently underway to decrease the incidence of onchocerciasis, Chaga’s disease, and malaria, however Guatemala still has more cases of Malaria than any other country in the Americas. HIV/AIDS is a growing problem in the nation with insufficient antiretroviral drugs available and a poor infrastructure in place to distribute those that there are[viii].

Dr. Paat’s medical brigade has become an important component of the health care delivery system in Guatemala.  The vast majority of health care professionals are in the major metropolitan areas.  The medical brigade serves the rural populations by traveling to San Lucas Tolimán to bring care to the people of the villages surrounding the town.  We act as a first line treatment and diagnosis team that also refers patients and coordinates travel the town clinic when necessary.  We work in conjunction with the local health coordinators which consequently maximizes our service to those with the greatest need. It also permits coordination of our visit to provide care to those not seen by other recent medical brigades in the area. Our brigade works with health coordinators to facilitate follow-up and specialty care for diabetics and those patients with individual needs. Statistics are maintained for al patient visits and used in order to direct and improve future brigade visits.

• All participating 4th year medical students serve as team leaders and are responsible for coordinating and collecting all participating students’ Global Health paperwork. Upon successful completion (via MedEd evaluation) 4th year students will receive 3 clinical med away elective hours/credit for 2-week med away elective for serving as team leader on the mission.

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Haiti

1. Pestel Haiti; Franciscan Health System, Mt. Carmel Hospital, Columbus with Dr. Richard Paat: recurring yearly; 8- 10 days in January

Dr. Paat’s Course Description: Students will be given an opportunity to travel with other health care professionals to a foreign country and deliver care to those in need.  The specialty of medicine will be dependent on the attending physician. Students will gain experience in developing a differential diagnosis and treatment plans for patients with various medical and surgical problems. 

Dr. Paat’s Team Letter: On Tuesday, January 12th, a 7.0Mw earthquake devastated Port-au-Prince. The Haitian government estimated that 230,000 people died and that 1,300,000 were made homeless.  Most of the homes, commercial buildings, and health care facilities collapsed or were severely damaged. The world responded with an outpouring of humanitarian aid. Locally, International Services of Hope (ISOH) and the Special Commission On Relief and Education (SCORE) mobilized a 23 member medical team that worked with Partners in Health at Double Harvest Hospital and in the tent cities. Our teams treated 1,600 medical patients and performed 100 surgeries in the immediate aftermath of the earthquake and its numerous aftershocks. We were struck by the faith and resiliency of the Haitian people despite the loss of nearly everything.

ISOH has continued its long standing relationship with Baptist Haiti Mission and sent palates of food and medical equipment to Double Harvest. Pierre Pierrot, a Haitian medical student that worked with our team, received invaluable medical training in Toledo. In August 2010, Dr. Jean Claude Bernard, Chief of Staff of the Baptist Haiti Mission Hospital in Fermathe received an emergency cardiac stent procedure at St. Luke’s Hospital in Maumee. On the 1st anniversary of the earthquake disaster, a second medical team from ISOH/SCORE committed themselves to assist the ongoing medical needs of the Haitian people in Fermathe. We treated 1,300 patients in local schools and tent cities and performed 30 surgeries in the hospital. A third medical team travelled back to Fermathe in January 2012 and treated 1000 patients, trained 10 local health promoters, and distributed 100 water filters to provide clean water to the communities for 3 years.

After the earthquake, I assisted a young man from the Pestel region of Haiti receive a heart operation at St. Vincent’s Medical Center in Toledo. He was sponsored by the Sylvania Franciscan Sisters from Lourdes University. That started talks that resulted in plans for the January 19 – 27, 2013, 4th annual medical mission to Haiti, this time, partnering with the  Franciscan Sisters that have been working in Ferrier, Haiti since 2001. Last year’s mission was able to treat about 2,000 patients. In addition, we trained 16 health promoters from the local villages, and brought in 100 water filters that can provide clean water to a family for 3 years. On January 11th, we embark on our 5th annual medical mission, returning back to Ferrier, Haiti.

An article form Catholic Health World in March 24, 2012 provided the following information.  Pestel is a coastal town on the southern peninsula of Haiti. The area is poor, even by Haitian standards. The local clinic has an RN, LPN and several other part-time staff. They are open one day a week and visit villages giving health care presentations the rest of the week. Sr. Josephine (Jo) Dybza O.S.F, and Sr. Fidelis Rubbo O.S.F. live in the mountain village of Ferrier. Their house has no indoor plumbing or electricity. They use an outhouse and kerosene lamps but do have a small solar panel and generator for charging phones and laptops for their limited internet access. They have to walk up the mountain to make international calls. The Catholic school in Pestel has a lunch program provided by Catholic Relief Services. Ferrier was about 60 miles from the epicenter of the earthquake and their clinic only sustained a cracked wall.

The region suffers from the Cholera epidemic, lack of clean water, malnutrition, parasites, TB, malaria, and AIDS. The clinic has a program for malnourished infants and children, a midwife training program and a largely free program for pregnant mothers and newborns.  The clinic trains village health care monitors. More urgent health problems go the hospitals in Port-au-Prince. They are sponsoring a second young woman through nursing school. Dr. Ben Fredricks of Hershey Medical Center has established a deworming and Vitamin A program that reaches 12,000 children.  He is working on funding to drill up to 20 wells in the area to assist during the drought season. Dr. Ben actually managed to bring Miss and Mr. World to visit Ferrier last March! Didn’t know there was a Mr. World did ya? The sisters also develop Haitian leaders through a development group, Christians Progress Together (KPA) that has programs on health and economic development, micro-crediting, an agriculture program to help farmers grow vegetables and peanuts, and a sewing center.

A new two-story, eleven room guest house with electricity, plumbing and screens was recently completed last year, built by funding from Sylvania Franciscan Health. It can house 13 people, and that is where our medical team will be staying. (Of course we have 21, so some will be sleeping on mattresses on the floor.)

• All participating 4th year medical students serve as team leaders and are responsible for coordinating and collecting all participating students’ Global Health paperwork. Upon successful completion (via MedEd evaluation) 4th year students will receive 3 clinical med away elective hours/credit for 2-week med away elective for serving as team leader on the mission.

BACK TO LOCATIONS

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Honduras

1. La Esperanza, Honduras with Dr. Richard Paat: recurring yearly; 8- 10 days in early March

Dr. Paat’s Course Description: Students will be given an opportunity to travel with other health care professionals to a foreign country and deliver care to those in need.  The specialty of medicine will be dependent on the attending physician. Students will gain experience in developing a differential diagnosis and treatment plans for patients with various medical and surgical problems. 

Dr. Paat’s Team  Letter: Our first medical mission to Honduras came at the request of the Honduran and U.S. governments after Hurricane Mitch devastated the country.  We were the 1st team into the Marcovia region.  The mission resulted in the building of a new town and a long term commitment of mission teams from Toledo to assist the Honduran people.  Our first 4 teams traveled to Marcovia and Danli.  In 2001, we started bringing teams to the rural mountain town of La Esperanza. The Lions Club of La Esperanza coordinates our activities.  Their hospitality, as you will soon see, was so overwhelming, and the need so great, that we decided to make La Esperanza our home base.

Over the past 12 medical missions, we have treated more than 19,350 patients, 2 little girls were brought back to Toledo for life-saving surgeries, and Dr. Ratliff, a Honduran surgeon, was trained at St. Luke’s Hospital in laparoscopic surgery.  Three years ago, our team brought down a donated ambulance and started a clean water filter program in 3 villages, and last year, we started a Health Promoter Project. Just as important, about 330 medical missionaries received a life-changing experience to help them become better health professionals.

• All participating 4th year medical students serve as team leaders and are responsible for coordinating and collecting all participating students’ Global Health paperwork. Upon successful completion (via MedEd evaluation) 4th year students will receive 3 clinical med away elective hours/credit for 2-week med away elective for serving as team leader on the mission.

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Philippines

1. Aquinas University, Legazpi, Philippines with Dr. Richard Paat: recurring yearly; 8 – 10 days in April (around Easter)

Dr. Paat’s Course Description: Students will be given an opportunity to travel with other health care professionals to a foreign country and deliver care to those in need.  The specialty of medicine will be dependent on the attending physician. Students will gain experience in developing a differential diagnosis and treatment plans for patients with various medical and surgical problems. 

Dr. Paat’s Team Letter: The Special Commission on Relief and Education of the Filipino Association of Toledo is a non-profit foundation. Our first medical mission to the Philippines was in 1994. We work in conjunction with Medical Missions, Inc. from the University of Santo Tomas, Manila. UST is the oldest university in the Philippines and is more than 400 years old. MMI has been performing medical missions year round to the far flung regions of the Philippines for over 52 years. MMI was inducted into the Medical Mission Hall of Fame at the University of Toledo. SCORE and MMI teams have worked together on 16 prior missions, treating more than 38,000 patients and performing 4,000 major and minor surgeries in some of the most underserved areas of the Philippines. We recently performed missions this past November and December in the immediate aftermath of super typhoon Yolanda to provide medical relief to the Aklan region of northern Panay Island and to the Tacloban area on Leyte Island. We are joining forces again with a 22 person SCORE contingent and an 80 person UST team to conduct a major medical, surgical, dental, and ophthalmologic mission at Aquinas University in Legazpi, Luzon Island.

• All participating 4th year medical students serve as team leaders and are responsible for coordinating and collecting all        participating students’ Global Health paperwork. Upon successful completion (via MedEd evaluation) 4th year students will receive 3 clinical med away elective hours/credit for 2-week med away elective for serving as team leader on the mission.

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Nicaragua

1. Nicaraguan Ministry of Health, Leon, Nicaragua with Dr. Linda Speer: recurring yearly; 8 – 10 days in August

Dr. Speer’s Course Description: We collaborate with the Nicaraguan Ministry of Health through their employed physician, Dr. Alonso Medina. He also has a teaching appointment with the medical school in Leon. Dr. Medina spends the week with us and participates actively in student teaching. We purchase services for food, lodging, transportation, and translation from El Aydante, a US-based non-profit social service organization.

This experience also gives opportunity to develop Spanish language skills, work with translators, appreciate the similarities in primary care needs of another population with populations in the U.S, participate in a rich service learning experience, and develop team skills through an interprofessional learning experience with one or more of the following disciplines: medicine, nursing, physician assistant studies, pharmacy, and physical therapy.

Dr. Speer’s Elective Description: Nicaragua has a total population of 5,743,000 people with a life expectancy of 71 for males and 77 for females. 39% of their population is under age 15 and nearly 41% of their population is in a rural setting. The climate is hot and humid with only two seasons, a wet season (from May to December) and a dry season (from January to April). Temperatures range from 68oF to 93oF throughout the year. Nicaragua is the second poorest country in the western hemisphere with a probability of 26 in 1,000 dying under the age of five.

A mixture of Spanish and Creole, Nicaragua has a unique cuisine. Their staple ingredient for meals, desserts, and drinks is corn. A typical meal includes traditional crops grown in Nicaragua such as corn, beans, plantains, and peppers and may include meat or seafood. Fruits used in the region include mango, papaya, bananas, avocado and many others. A few common meals include Gallo Pinto (fried rice, onion, sweet pepper, beans with garlic), Nacatamal (dough filled with pork or chicken, rice, potatoes, tomatoes, onion and sweet pepper which is wrapped in plantane leaves and allowed to boil for five hours before eating), and Quesillo (tortilla filled with cheese, with onions, vinegar, and cream on top).

The country’s two main nationality groups are Caucasian and Mesitzos. Western Nicaragua was originally colonized by Spain, and this is still reflected in their culture. A majority of Nicaragua speaks Spanish and is also Roman Catholic. The British once ruled Eastern Nicaragua. Compared to the West, more of the population speaks English and there is a greater percentage of Protestants in the East. Other religions included Moravian, Jehovah’s Witnesses, Judaism, and Buddhism.

The health sector in the Nicaragua is managed by the Ministry of Health (MINSA) who provides, coordinates, supervises, regulates and monitors all health activities.  This responsibility is delegated to MINSA in article 59 of the Nicaraguan constitution which states that all citizens have the equal right to health services and that the State is responsible for providing those services. Per every 10,000 Nicaraguans there are 20 physicians and 72.5 nurses and midwifes (WHO, 2005).  In general, the country has high rates of maternal and child mortality and considerable morbidity as a result of communicable disease including diarrheal, respiratory, vector-borne, and sexually transmitted infections, with diseases of the respiratory system being the leading cause of morbidity.  It is estimated that 20.4% of children suffer from chronic malnutrition and 5.1% suffer from severe chronic malnutrition.  In recent years, there has been an increase in unhealthly lifestyle behaviors resulting in a 10% increase in the prevalence of diabetes from 1992 to 2005 from 8.9 to 18.98% per 100,000 people.  Cervical cancer is the leading cause of tumor related death in women.  The prevalence of cervical cancer in 2002 was determined to be 13.9% in women over age 15.  Additionally, one of the most vulnerable populations to disability and chronic diseases is the growing older population in Nicaragua, however 90% of this population has no social security coverage and there are currently no programs designed to meet the special health care needs of this population in the country (PAHO, 2009).

While in Nicaragua, the medical mission team works closely with MINSA physician Dr. Alfonso Medina and pharmacist Mario Rivas to determine which villages we will serve each year.  We have worked closely with Dr. Medina and Mario for the past few years and have developed a relationship that affords medical students the ability to learn about cultural aspects of medicine in Nicaragua from a multidisciplinary perspective, in addition to developing clinical skills.  Both Dr. Medina and Mario travel with the teams to all clinical sites.  The team primarily serves rural communities 30-90 minutes outside of Léon.  Accordingly, we serve communities with limited access to National health services.  During the course of a trip 5 villages are visited (one per day).  Our team provides primary care to adults and children as well as women’s care, dental services and for the first time this year, physical therapy.  Through our collaboration with Dr. Medina we are able to refer patients in need of further care beyond what we can offer to him to provide some degree of continuity of care.  We provide cervical cancer screening for any of the appropriately aged women in the clinic and work with the local health care administration through Dr. Medina for appropriate follow up.  Dental services are primarily preventative including fluoride treatments and dental sealants.  Statistics on all patients seen are monitored by the team and MINSA, through our collaboration with Mario Rivas.

• All participating 4th year medical students serve as team leaders and are responsible for coordinating and collecting all participating students’ Global Health paperwork. Upon successful completion (via MedEd evaluation) 4th year students will receive 3 clinical med away elective hours/credit for 2-week med away elective for serving as team leader on the mission.

BACK TO LOCATIONS

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Contact

All Global Health elective inquiries should be directed to Ms. Deborah Krohn, Global Health Program Advisor:

Deborah M. Krohn, M.Ed.
Global Health Program Advisor
College of Medicine and Life Sciences
The University of Toledo
2801 W. Bancroft St.
Stranahan Hall, Room 2017/Mail Stop 103                      
Toledo, OH 43606
phone: 419.530.2549
fax: 419.530.5353
email: deborah.krohn@utoledo.edu