August 2018
by: Kira Battle

I have met many students interested in “global health,” and most are unsure what they could do to advance their understanding of this field. During my time as a student I was fortunate to have a variety of experiences, which included service learning, local community outreach and collaborative research. This blog is a brief reflection of some of my student experiences that I hope are thought-provoking and supportive of global health educational opportunities.

Service Learning Abroad

Short-term service trips were my introduction to global health. One in particular was a 10-day intensive neuro-rehabilitation camp in Jamaica for post-stroke patients. Under the guidance of our professor and the head of the local clinic, I was partnered with one patient to complete approximately 6 hours of therapy a day for one week, pre- and post- home assessments and outcome measures, and a final community excursion.

Roads throughout the local village (Photo by Lorraine Schrand)

I gained a quick appreciation for day-to-day challenges, especially in creating a plan of care and goal setting in the face of cultural differences. What about the patient’s home environment? Steep hills and rough gravel most likely comprised the terrain necessary to navigate to the front door. What were the patient’s responsibilities at home? These often included collecting buckets of water from rainwater storages and food preparation in deep squatted positions. Such answers meant that baseline functions for these patients were different from those to which we were accustomed. For my patient-partner, another primary goal was returning to work as a local cobbler. In unfamiliar territory, it was guided reflections with our professor and the local clinicians that helped us plan ways to make treatment interventions purposeful, meaningful and functional. I have fond memories of him demonstrating his craft and using his own shop materials to create home exercises.

Outdoors of the local clinic (Photo by Lorraine Schrand)

This was also the first time I partook in conversation about the relationships created in global health. We constantly reflected on being respectful of our hosts and receptive of their advice. We were providing manpower for the camp under their guidance, which I felt important. Local clinicians helped us adapt our treatment techniques and consider ways to use our environment around us. With few plinth tables, manual therapy was sometimes completed with a mat on the ground, which left my back in considerable pain until a local therapist advised me in handling techniques. Local clinic assistants also helped me during home visits, teaching me how to be a respectful guest and pointing out unfamiliar household responsibilities that allowed me to gather information I would have otherwise missed. I was experiencing first-hand the importance of partnership.

Local Community Outreach

Traveling is not always required for working with cultures and situations vastly different than one’s own. Within my community, a collaborative outreach program to refugee families was established that incorporated medical, nursing, global health and physiotherapy students. The goals of this initiative were to assist these families in navigating the local healthcare system and increasing health literacy within their new environment.

Before even working with a family, the preparation involved with this organization proved to be an educational experience, further underscoring the value of respectful partnership. Our group met with local refugee support organizations. These groups introduced us to basic considerations unique to working with this population. Although I felt confident listening to patients, I realized I would still feel very confused and uncomfortable identifying mental health red flags, something that requires special consideration in populations that may have experienced recent trauma. I was unaware of the numerous legal documents needed for these families to not only possess, but to understand, which exemplified another possible barrier to healthcare. I was humbled by the importance of being receptive to education and dialogue before working with populations so vastly different from those to which I was accustomed.

Furthermore, establishing an initial relationship with the family still required attention to strong cultural differences. Myself and a medical student assisted a Syrian family. As an American, I was ready to dive into our lessons, wanting to give the family as much educational information as I could in an hour. My partner, a medical student from the Middle East, encouraged me to slow down and allow the family to first treat us to food and refreshments. Every visit began with Arabic coffee and sweets. On rare occasions we lost the battle to politely decline dinner, which was delicious and joyously full of curious questions from the children. I felt uncomfortable, but accepting their generosity played a major role in developing a relationship that opened them to our assistance. Furthermore, it humbled me to realize that I was inappropriately seeing this family as a project rather than welcoming them as new people in my life and community. 

Research Collaboration

Research collaboration is another possible educational opportunity. For me, this came through collaboration with a neurosurgical team working with partners in Uganda to increase capacity of care. Each step of this experience reinforced previous lessons or taught new ones.

First, research collaboration gave new depth to respectful partnership. Designing the project meant seeking ethical review from both my home and host institutions. Mentors guided me in respecting permission not only to collect data, but for which locations I was allowed to be within the host hospital. In hindsight these things seem obvious by today’s standards, but mentors shared past experiences observing researchers who simply walked into hospitals in lower resourced settings and collected data, taking advantage of a lack of ethical standards. Unfortunately, I later observed remnants of this behavior when some foreign providers walked freely onto wards and interrupted care, demanding assistance without permission to be in the area. I am thankful to those mentors who openly assist one another through pre- and post-departure reflection in an attempt to avoid such mistakes.

Second, the research project reinforced initial lessons that cultural differences can mean different functional norms. For example, I observed and graded patients’ physical activity in a neurosurgical ward. Originally, laying down was graded as minimal movement and sitting on the edge of the bed was graded as higher activity than sitting in a bedside chair. The only issue was that some patients decided to lay under the bed, and the “chair” next to the bed was a bucket that required more hip/knee flexion and core balance than sitting on the edge of the bed. These are the smaller, more humorous, examples that underscored the importance of local participation at all levels of research design. I appreciate the chance to first experience them as a student with mentored guidance to mitigate larger errors. 

Former entrance to the Physiotherapy Department at
Mulago National Referral Hospital in Kampala, Uganda
(Photo by Physiotherapy Department)

This opportunity held unique lessons as well. One, in particular, was building on existing projects rather than working in isolation of other efforts. Within “global health,” innumerable projects by multiple institutions are located in the same areas of the world, working on similar initiatives. So why always start something completely new? I was fortunate to meet an established group within my institution, and the beauty of physiotherapy is that it is a field relevant to all areas of healthcare. While cooperation among multiple partners requires comprehensive planning and coordination, our field is in an ideal position to support intercollegiate and multidisciplinary collaboration with existing efforts.

Final Thoughts

Lessons that come with working across national and cultural boundaries can be overwhelming. While my experience is still limited, I have found it helpful to reflect on broad-based questions such as: What service are you trying to provide? Who are you working with? Where are you and what are some of the cultural norms to consider? Why are you going to this particular location? Answers to these questions allow constant reflection for how to conduct oneself with each varying situation. In some moments, I was there to go with the flow and not be disruptive. In some cases, I was invited to be the foreigner, letting them ask me questions about myself and observe my behavior, making this international experience a two-way street whenever possible.

My experiences were not without mistakes, and I am thankful for continued reflection with colleagues and partners to improve ourselves. During one conversation, a fellow Ugandan physiotherapist opened up about his concern that outsiders come for short-term projects. Despite the best of intentions, he stated that energy is quickly lost and initiatives abandoned prior to completion. In other places, this same topic arose as I was shown equipment and project designs sitting in storage. I appreciated the honesty of these mentors. As healthcare providers we must consider our long-term impact, and sustainability should be a focus in all efforts.

Lastly, I have also learned that if opportunities are not available, one can push to create them. Even if you cannot participate fully in what you are advocating, merely playing a role in its establishment is a relevant and a valuable experience.

To have so many ways to connect globally as a student is unique. It is my hope that physiotherapy programs will expand these opportunities. It is an ideal time to take the first steps in international work, when there is access to resources, peer support, and, most importantly, guided reflection and structured mentorship in training future generations.

Kira Battle completed her undergraduate degree at the University of North Carolina at Chapel Hill, majoring in both Japanese Language and International Studies, focusing on East Asian Politics. After graduating, she worked for four years as an educator in rural Japan. While she initially was intent upon a career in interpretation, a unique encounter with a student introduced her to the field of physiotherapy. She since returned to the United States and completed her Doctorate in Physical Therapy at Duke University. Her clinical interest is neurorehabilitation, and her long-term passion is to work in building capacity of care in lower resourced settings, particularly in post-conflict and post-disaster regions. In September she will start her first job abroad in Salmiya, Kuwait.