Global Health, Nephrology, and International Rotations

Aditya S. Pawar

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Sarvie Esmaeilzadeh

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The past two decades have seen a surge in kidney disease with a significant impact on morbidity and mortality worldwide. An estimated 5 million to 10 million deaths are attributable to kidney disease annually (13). This has economic repercussions worldwide, with a larger estimated impact on low- and middle-income countries.

Multiple organizations have developed campaigns to increase awareness among both physicians and the public. For example, the International Society of Nephrology’s (ISN) “0 by 25” program aims to prevent avoidable death from acute kidney injury by 2025 in low- and middle-income countries (4,5).

In the United States, we are privileged to have access to the most advanced techniques and resources to care for our patients’ conditions. Moreover, nephrology training is well structured, and access to resources helps further patient care and research. Increasingly, a growing body of literature in nephrology is shedding light on global disparities in the effective prevention and treatment of kidney diseases (5). The density per population of nephrologists varies, with more prominent deficits noted in lower- and middle-income countries, particularly in Africa and South Asia (Figure 1) (6).

Global distribution of nephrologists, treated ESRD

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The combination of public health and nephrology is an interesting field, and with existing disparities, this combination is the need of the hour. A particular focus on training and education programs is required to help build a workforce with a capacity for sustainable growth. Exposure to international health training during nephrology training may strengthen the nephrology community worldwide by creating and recruiting a workforce.

Rotations during residency are cited as one of the most important experiences influencing career decisions (7). A career in international health can include research, clinical medicine, medical education, and population and global health. Skill sets such as point-of-care ultrasound, basic laboratory techniques (gram stain, acid-fast stain), x-ray interpretation, cultural competency, advocacy and policy, quality improvement, and patient safety are useful. Early identification in either primarily clinical activity or global health and systems policy may help in deciding which skills to focus on during training.

Increased trainee participation requires effort on the part of trainees and organizations such as the American Society of Nephrology and the ISN, specifically aimed at involving trainees in field-based hands-on experience and in strategic systems planning. At present, few nephrology programs offer international rotations, and expanding such experiences to all trainees may increase participation.

International rotations have helped us immensely to grow both professionally and as individuals. Such rotations offer unmatched experience in global health delivery, and the principles learned can be applied to providing high-value care in the United States (i.e., judicious use of resources and exposure to different pathologic conditions) (8). On the other hand, short-term rotations can easily be mistaken as “medical tourism” and therefore require preparation, an understanding of pros and cons, and a healthy awareness of how to maximize collaborative learning for the partner organization and for oneself. Understanding the complexities of global health delivery before visiting another country can make a significant difference, and adequate preparation for such a rotation is highly recommended. The Global Health Practice Certificate by Unite for Sight is a good start (www.uniteforsight.org/global-health-university/global-health-practice-certificate/) (Table 1).

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Practically, international rotations often benefit visiting trainees, especially resident trainees, more than the partner institution. It is important to build long-term relationships and collaborations focusing on the needs of the partnering organization, establishing a longitudinal presence. For example, the development of teaching curricula and longitudinal visits from trainees and staff can help build the capacity of local participants and encourage sustainability. Among such programs are the Botswana/Harvard partnership and the Yale Global Health Scholars Program.

To understand context-specific hurdles and successfully plan and implement programs can be challenging. It is crucial to involve and align goals with local priorities. Local residents have a thorough understanding of barriers to care delivery within their environmental context. Even in clinical settings, the involvement of local doctors is essential because they understand the needs and situation of the local community better, including etiologic factors and disease distribution patterns. This has an impact on sustainability and therefore on long-term population health outcomes, given the importance of physician-patient continuity. Medical treatments without adequate follow-up and support can have deleterious effects, and a visiting physician must maintain a primary focus on skills transfer to those providing care to the local population on an ongoing basis. Such an approach is important for implementing a successful international exchange program.

Noncommunicable diseases, including chronic kidney disease, are major contributors to mortality in low- and middle-income countries. The improvement of nephrology care worldwide can be a cost-effective intervention to curtail said mortality and morbidity (9). When addressing strategies for improving care in such settings, there are challenges and hurdles at every corner that may be overcome with the right preparation and approach. As trainees, we can contribute to nephrology education with a focus on improving the local workforce in resource-limited settings. Individual initiative and adequate support from capable organizations can improve the recognition and care of patients with kidney diseases worldwide.

We thank Drs. Fredric O. Finkelstein, Yale University, New Haven, CT, and Robert Rope, Oregon Health Science University, Portland, OR, for guidance in writing this article. Aditya S. Pawar would like to thank and acknowledge support from Mayo International Health Program and ISN in making his travel possible.

July 2019 (Vol. 11, Number 7)

References

1. GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1459–1544.

2. Liyanage T, et al Worldwide access to treatment for end-stage kidney disease: A systematic review. Lancet 2015; 385:1975–1982.

3. Mehta RL, et al International Society of Nephrology’s 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): A human rights case for nephrology. Lancet 2015; 385:2616–2643.

4. Feehally J. The ISN 0by25 Global Snapshot Study. Ann Nutr Metab 2016; 68:29–31.

5.Harris DCH, et al Increasing access to integrated ESKD care as part of universal health coverage. Kidney International 2019; 95(4s):S1-S.5.

6. Bello AK, et al Assessment of Global Kidney Health Care Status. JAMA 2017; 17:1864–1881.

7. Daniels MN, et al Career interest and perceptions of nephrology: A repeated cross-sectional survey of internal medicine residents. PLoS One 2017; 12:e0172167.

8. Sawatsky AP, et al Eight years of the Mayo International Health Program: What an international elective adds to resident education. Mayo Clin Proc 2010; 85:734–741.

9. Couser WG, et al The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney International 2011; 80:1258–1270.