AAP eBooks

Principles of Global Child Health: Education and Research

Edited by Danielle Laraque-Arena, MD, FAAP and Bonita F. Stanton, MD, FAAP

This indispensable resource provides a cohesive, sustainable, and ethical approach to medical education and research that addresses the health needs of children locally and globally.


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      This chapter reviews global health education and research within a community-oriented framework emphasizing social accountability of these 2 academic spheres. The rationale for this approach is the understanding that in low-, lower-middle–, upper-middle–, and high-income/ resource countries throughout the world, research should be guided by translational steps that ultimately lead to improvement in the care of individuals and contribute to the health of populations locally and globally. Additionally, professional education, profoundly affected by the available environment for clinical training, must display alignment with a valid and socially responsible clinical venue; for example, one based on ethical practice, responsiveness to health needs,1 and broad epidemiological principles of community pediatrics.

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      As our understanding of the interdependence of the world’s nations has evolved, greater attention and scrutiny have been focused on the goals of improved national and international health and the processes for achieving these outcomes. The rationales for action in support of health within a country, within a region, and across the globe have changed over the last half century, as has our understanding of the consequences of these approaches. This chapter reviews the evolution over the course of the 20th and 21st centuries of our understanding of international and global health and how this evolution has been reflected in and changed the training of the medical workforce. The chapter describes the emergence of multiple forces and agencies aligned toward the goal of a global perspective on health and well-being with resources and training reflective of this overarching vision. The chapter concludes with a discussion of the critical components of continued progress toward realization of global health, especially as they relate to evidence-based training and research and deployment of the global medical workforce.

    3. Page 43

      The United Nations Millennium Development Goals (MDGs) adopted by world leaders in 2000 aimed to address some of the most pressing global issues of our times: extreme poverty, unequal health, and inequities in development. The MDGs, a set of interrelated targets to be met by 2015, catalyzed political commitment toward improving child survival and maternal health. Millennium Development Goals 4 and 5 called for a two-thirds reduction in the younger-than-5 child mortality rate and a three-quarters reduction in the maternal mortality ratio, respectively, from 1990 base figures.1

      Although concerted global efforts have led to substantial reductions in maternal and child mortality over the past 25 years, MDG 4 and 5 targets have not been fully realized. Only 62 of the 195 countries with available estimates achieved the MDG 4 target, of which 24 were low-income and lower-middle–income countries.2 Only 2 regions, East Asia and the Pacific (69% reduction) and Latin America and the Caribbean (67% reduction), met the target at a regional level.2 For MDG 5, of the 95 countries that had a maternal mortality ratio of more than 100 in 1990, only 9 achieved the target for reduction in maternal mortality: Bhutan, Cambodia, Cape Verde, Iran, Laos, Maldives, Mongolia, Rwanda, and Timor-Leste.3 As we celebrate the fact that the global younger-than-5 mortality rate and maternal mortality ratio have fallen by 53% and 43.9%, respectively, since 1990, we also face the sobering reality that high numbers of women and children are still dying every year, largely due to conditions that could have been prevented or treated if existing cost-effective interventions were universally available.2–4 The burden of mortality also remains unevenly distributed, with the largest numbers and highest rates of maternal and younger-than-5 deaths concentrated in countries of sub-Saharan Africa and South Asia, especially in lower-income countries and among fragile states, especially those with ongoing conflict.2,3,5

      2015 marked the end of the MDG era and the beginning of a new global framework, the Sustainable Development Goals (SDGs). This new framework presents an opportunity to leverage the momentum built over recent decades to tackle global inequities in maternal and child health. Of these SDGs, goal 3 also calls for an end to preventable deaths of newborns and children younger than 5 years, as well as a reduction in maternal mortality to less than 70 per 100,000 live births, by 2030.6 Achieving this target would require overcoming barriers and inequities in access to quality health services and, thus, implementing strategies to reach all mothers and children, including those who are most vulnerable, remote, and at risk. In this chapter, we discuss the current burden of younger-than-5 and maternal mortality, barriers contributing to health inequities, and, finally, evidence-based strategies to bridge these gaps.

    4. Page 61

      This chapter describes the importance of using standard data for decision-making at local and national levels on reportable diseases and conditions of public health significance. In addition, the chapter will provide an overview of the use of data to monitor interventions and detect outbreaks and emerging conditions. Lastly, this chapter will cover the importance of data, data sources, key indicators of childhood health, the role of millennium and sustainable goals, and training needs.

      In all health care settings, whether population based or institution specific, the importance of effective use of data for planning and monitoring cannot be overstated. Implementing interventions and programs, even those that are evidence based, without the benefit of a local needs assessment and continuous data monitoring may not succeed due to erroneous targeting and inability to monitor progress. To ensure that public health and clinical programs are targeted to the setting and population in which they will be implemented, standard data collection and analysis is critical. The use of standard indicators allows for comparison across countries or regions.

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      The discussion of global child health should include consideration of the economic and political realities of different countries. These realities will certainly reflect on the health profession educational systems and research capabilities of each country. The categorization of countries is usually based on income: low, lower-middle, upper-middle, and high income/resource. However, in this chapter, we propose that income is not the only determinant of how each category of countries proceeds or should proceed to address health imperatives.

      Through technologies not available even a decade ago, all countries, regardless of income level, have greatly increased internal and external connectivity. One example is the availability of cell phones in the most impoverished countries. These technologies have not only quickened the pace of development but also allowed for a rethinking of the progress possible and the just-in-time response to health emergencies, scientific advancements, and the sharing of best practices across borders. This information revolution can, we propose, lead to recognition of the mistakes of high-income, industrialized nations and, thus, avoidance of repeating those mistakes. Disaggregation of health data reflects health disparities within each of the country income categories, signifying a need for a more complex analysis of educational and research approaches to resolving health concerns. For low-income countries it may be possible to tackle basic survival problems resulting from extreme poverty, while concurrently applying 21st-century solutions to improve health outcomes more quickly.

      Thus, we propose a new matrix for the development of child health that embraces new-century transformation of educational and research efforts (Figure 5-1). Illustrative case examples will demonstrate the application of this matrix in educational efforts in each country income/resource category. At the root of this analysis is the recognition that economic inclusion and social justice must drive changes to improve the health of individuals and populations in all countries.

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      This chapter addresses the knowledge, skills, attitudes, and qualities— the competencies—essential to operate effectively in an administrative role at various levels, from the faculty person to the professional association. These are organized under broad domains.1

      This chapter discusses the operational or administrative attributes of key individuals, the larger entities in which they operate, and how they might demonstrate their competency—what they actually do—as a reflection of their knowledge, skills, and attitudes. Administrative competencies in global health might be manifest as the philosophical principles incorporated into their mission, the goals and objectives within their strategic plan, and the policies and managerial decisions they incorporate in their activities.

      The entities with administrative duties discussed include global health faculty and program directors as well the larger entities of departmental and division structures, the entire health care or university system, and professional societies.

      Competencies imply action, as opposed to simple statements reflecting knowledge or belief, and, thus, need to be measurable to have relevance. Defining basic global health-related competencies increases transparency and induces change toward the ideal. Clear and measurable competency parameters are consumer friendly; the potential undergraduate, resident, or faculty candidate will incorporate these measures into his or her decision-making process when looking for a position. Moreover, and of critical importance, those on the other end of our attentions—the sites to which we send our students, conduct our research, and expand our institutional reach—can monitor and compare how they fare in a particular partnership by comparing it to a transparent and recognized standard. Thus, benchmarking levels of administrative competency at the broader institutional level can be true to the values of partnership and set the stage for bidirectional interaction.

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      In high-income countries, global health has emerged as a core component of medical education across most medical disciplines. Approximately two-thirds of US pediatric residency programs offer the opportunity to complete short-term global health electives in low- and middle-income countries,1 and about one-fifth of residents pursue such an elective.

      Internal medicine, emergency medicine, and pediatrics now all offer formal fellowship opportunities in international (ie, global) health. Global health opportunities among Accreditation Council for Graduate Medical Education–accredited pediatric subspecialty fellowship programs are limited but increasing, as noted by its online report.2 Global health has become a branch of science supporting institutionalized education. A rapidly expanding experience indicates that effective global health education should train students to understand global health statuses, to investigate global and local health issues with a global perspective, and to devise interventions to deal with these issues.3

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      Healthy children are the foundation of sustainable development. Major research advances have resulted in significant advances in infant and child health, but health inequities among children in high-income, upper-middle–income, and low- and middle-income countries persist. For children in all countries of the world, research remains vitally important. Despite the importance of research, communities may be wary of participating in research for at least 5 reasons: they may remember a history of unethical and dangerous research activities; they may have different values than the researchers; they may have different ways of knowing than the researchers; they may have different views about the significance and appropriate uses of samples of their blood or other tissue specimens; and they may fear stigmatization from participation in research studies. The Academic Pediatric Association Global Health Task Force developed a consensus statement on faculty competencies, including those needed for research in global settings. Researchers from all involved countries should agree on the research goals of the involved institutions that align with their respective priorities. They should translate the research into action benefiting the host country. Prioritization should be place on those health research activities that address priority health concerns of the community, region, or nation they have the mandate to serve. Best practices for faculty and students are to follow the principles of community-based participatory research (see chapters 1–5). Concerted efforts of international organizations, ministries of health of governments, multinational donors, academic centers, nongovernmental organizations, and communities will be required to reach the United Nations Sustainable Development Goals. The role of community-based participatory research will be integral to success.

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      The combined use of interprofessional models for research, education, administration, and clinical practice sets a framework for advancing public health. For the clinician, the pursuit of a career in global health often begins with a desire to establish or enhance patient care in countries or communities considered by many measures to be far less economically stable or technologically advanced than one’s own. Improving the treatment for or identifying novel strategies to prevent a specific disease motivates others. The successful development of the clinical aspects of a global health collaboration depends on adhering to the basic core principles of public health. Faculty practicing in settings outside of their home country need to develop, refine, and practice many of the skills acquired during training and through clinical practice experience but in the new context of understanding the unique aspects of clinical work in a new culture, usually with fewer or different resources than those to which they are accustomed. Competencies for global health faculty are grouped and discussed under 4 categories or domains: values and ethics, roles and responsibilities, communication, and team building and teamwork. Beyond these specific categories, additional special considerations merit discussion.

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      Purposeful and mindful leadership for global health incorporates the same principles as any leadership endeavor. Purposeful leadership requires a core dedication to the organizational mission. There cannot be purposeful leadership without authenticity of purpose—a true desire to lead for a reason, not just leadership for the sake of leadership. Mindful leadership requires attention to the many nuances found in a particular setting, culture, and system of care or organizational structure. In global leadership, mindfulness is critical to securing success. All leadership requires the blend of the drive of purpose seasoned with the humility of mindfulness. In the United States, medical education has been shaped by the confluences of accreditation and certification. Accreditation refers to the standardization of training programs. Certification refers to the demonstrated competence of individuals to practice their profession. It is a system of checks and balances that does not exist in many other global settings but one that might serve as an effective framework for others. Central to any leadership position is the ability to promote change. In the context of global health leadership in education, change is not the replication of the US system but the preservation and adaptation of the concepts of programmatic and individual improvement efforts.

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      Persistence may be defined as the quality that allows someone to continue doing something or trying to do something even though it is difficult or opposed by other people, or firm or obstinate continuation of advocacy despite difficulty.1 The first definition implies a long-term commitment to a program. It also implies seeing a project through and seeking opportunities to connect others when the time is right. The term “stickiness factor” from Malcom Gladwell’s book, The Tipping Point: How Little Things Can Make a Big Difference, has been brought into the global health discussion by Danielle Laraque-Arena, MD, FAAP, in her presidential speech at the 50th anniversary of the Academic Pediatric Association.2,3 The stickiness factor describes a desire to see programs through to sustainability with a more positive, fanciful lightness, not dogged determination like a bulldozer. As children and youth are given the tools to take ownership of their future with persistence and confidence, there may be no turning back.

      The fierce determination of community health professionals to ensure adequate, reliable, culturally appropriate, and sustainable programs and policies has come, in part, in the United States from the growth of support for such programs from the American Academy of Pediatrics (AAP).

      This chapter will briefly follow through the evolving trends and many key concepts as they helped to frame and guide the work of pediatricians and other health care professionals working with communities in the United States and overseas.

      Several key concepts that helped to support this effort were taken up by the AAP, including the Convention on the Rights of the Child, child-friendly places, concepts of equity and social justice, the Community Access to Child Health program, asset-based community development, the Anne E. Dyson Child Advocacy Award, and the Community Pediatrics Training Initiative, along with the requirement that residents have experiences and opportunities outside the hospital to work with community-based organizations and to learn principals of public health and service learning. The need for persistence will be shown throughout. All these concepts translate easily to overseas work, as we will show with 4 examples. The shared vision of seeking educational successes for all children who can grow up with knowledge of their own languages and stories is taking root across all borders. We are seeing in various countries the importance of spending time with a parent, teacher, or mentor starting at birth surrounded with love and words. The emphasis on the home language spoken freely around the newborn may perhaps mitigate a world fraught with violence, prejudice, and addiction, both in the family and community and in the world at large.

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      The global migration of children and families from one country to another has increased diversity of pediatric populations worldwide, requiring pediatric health care professionals to develop skills in cross- cultural communication. This necessitates the development of communication skills adapted for cultural and linguistic differences and an understanding of the unique social determinants that may affect newcomers to a host country, including the process of acculturation. Effective cross-cultural communication requires understanding one’s implicit biases that might affect the patient interaction and having appropriate interpreter services. Overall, cross-cultural communication is centered on obtaining the patient’s and family’s perspective of the patient’s malady to develop a therapeutic relationship that builds trust between the health care professional and the patient/family. Cultural competency curriculums developed to achieve this goal include the following 5 domains:

      1. Students’ understanding of the definition and rationale of cultural competency

      2. Influence of cultural/environmental factors

      3. Understanding the effect of stereotyping on medical decision-making

      4. Health disparities and factors influencing health

      5. Cross-cultural clinical skills

      Effective cross-cultural communication requires humility on the part of the health care professional as well. Although the term cultural competency implies an achievable competency, the true goal is to achieve efficacious cross-cultural communication skills, which become refined over time with interaction with patients from a variety of cultures, languages, and social-environmental backgrounds. With the growing diversity of children in the United States and in many other countries globally, the development and continued refinement of these skills is necessary to maintain clinical excellence in pediatric care around the world.

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      In 2010, the Neonatal Resuscitation Program became the first life support resuscitation program to formally incorporate simulation- based training with debriefing as an educational methodology. Concurrently, a simplified simulation-based neonatal resuscitation program called Helping Babies Breathe (HBB) was created, with the goal of providing low-cost, portable programming to teach basic neonatal resuscitation to birth attendants in low- and middle-income countries. Early studies evaluating the efficacy of HBB demonstrated that facility- based implementation has the potential to reduce rates of early (<24 hour) neonatal mortality and stillbirth. Subsequent investigations that have coupled HBB training with quality improvement efforts, ongoing practice, and refresher training have shown even greater effect on neonatal mortality and stillbirth rates. However, the ideal frequency of skills practice and refresher training required to retain resuscitation skills remains poorly defined. Challenges exist in defining optimal practices, as recommendations may vary by the cadre of health care professional, education level, and access to ongoing delivery room experience.

      While simulation-based strategies have been shown to be effective at improving educational and clinical outcomes, the use of simulation in global health settings is challenged by hurdles such as resource limitations (complex equipment, supply chain, and expense), time intensity, dependence on skilled educators, and acceptance of simulation as a teaching strategy.

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      Recent improvements in child health have led to substantial decreases in child mortality globally.1 While progress is still needed, especially in regions afflicted by conflict and political instability,2 the next step is to promote young children’s development and early learning so they can remain healthy, take advantage of growing educational opportunities, and contribute to their communities’ economic growth. Every year, approximately 249 million children, mainly from low- and middle- income countries, fail to reach their developmental potential in the context of poverty and related health, nutrition, and social factors.3 Recessions and climate change additionally contribute to loss of developmental potential globally.4–7

      While principles of early childhood development are universal, a global perspective must consider exposure to extreme poverty and high prevalence of infectious diseases, cultural context, and availability and type of resources. This chapter will describe biological and social factors that influence brain development and early learning and resilience, their cultural context, and examples of successful child development interventions globally. We also provide recommendations to rapidly accelerate the promotion of early childhood development globally with key strategies, including an emphasis on universal prevention programs rather than universal screening, multigenerational models that emphasize universal support for parents and targeted support for high-risk populations, integration of child development programs into child health and nutrition efforts, and use of technology.

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      Children in today’s ever-smaller, more densely populated, tightly interconnected world are surrounded by a complex array of environmental threats to health.1 Because of their unique patterns of exposure and exquisite biological sensitivities, especially during windows of vulnerability in prenatal and early postnatal development, children are extremely vulnerable to environmental hazards.2,3 Even brief, low-level exposures during critical early periods can cause permanent alterations in organ function and result in acute and chronic disease and dysfunction in childhood and across the life span.4

      The World Health Organization estimates that 24% of all deaths and 36% of deaths in children are attributable to environmental exposures,5 more deaths than are caused by HIV/AIDS, malaria, and tuberculosis combined.6–8 In the Americas, the Pan American Health Organization estimates that nearly 100,000 children younger than 5 years die annually from physical, chemical, and biological hazards in the environment.9

      Children in all countries are exposed to environmental health threats, but the nature and severity of these hazards vary greatly across countries, depending on national income, income distribution, level of development, and national governance.10 More than 90% of the deaths caused by environmental exposures occur in the world’s poorest countries6–8—environmental injustice on a global scale.11

      In low-income countries, the predominant environmental threats are household air pollution from burning biomass and contaminated drinking water. These hazards are strongly linked to pneumonia, diarrhea, and a wide range of parasitic infestations in children.9,10

      In high-income countries that have switched to cleaner fuels and developed safe drinking water supplies, the major environmental threats are ambient air pollution from motor vehicles and factories, toxic chemicals, and pesticides.10,12,13 These exposures are linked to noncommunicable diseases—asthma, birth defects, cancer, and neurodevelopmental disorders.9,10

      Toxic chemicals are increasingly important environmental health threats, especially in previously low-income countries now experiencing rapid economic growth and industrialization.10 A major driver is the relocation of chemical manufacturing, recycling, shipbreaking, and other heavy industries to so-called “pollution havens” in low-income countries that largely lack environmental controls and public health infrastructure. Environmental degradation and disease result. The 1984 Bhopal, India, disaster was an early example.14 Other examples include the export to low-income countries of 2 million tons per year of newly mined asbestos15; lead exposure from backyard battery recycling16; mercury contamination from artisanal gold mining17; the global trade in banned pesticides18; and shipment to the world’s lowest-income countries of vast quantities of hazardous and electronic waste (e-waste).19

      Climate change is yet another global environmental threat.20 Its effects will magnify in the years ahead as the world becomes warmer, sea levels rise, insect vector ranges expand, and changing weather patterns cause increasingly severe storms, droughts, and malnutrition. Children are the most vulnerable.

      Diseases of environmental origin in children can be prevented. Pediatricians are trusted advisors, uniquely well qualified to address environmental threats to children’s health. Prevention requires a combination of research to discover the environmental causes of disease coupled with evidence-based advocacy that translates research findings to policies and programs of prevention. Past successful prevention efforts, many of them led by pediatricians, include the removal of lead from paint and gasoline, the banning of highly hazardous pesticides, and reductions in urban air pollution. Future, more effective prevention will require mandatory safety testing of all chemicals in children’s environments, continuing education of pediatricians and health professionals, and enhanced programs for chemical tracking and disease prevention.

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      Community-based participatory research (CBPR), as a research paradigm emphasizing principles of participation, action, and empowerment, has been widely applied in public health areas to address health needs of local communities and reduce health disparities across ethnic, geographic, socioeconomic, and cultural groups. In this chapter, we briefly introduce the core concepts and main components of the CBPR approach, review its theoretical roots, and highlight its significance in connecting academic scholars and local partners and bridging research and practice. We illustrate the concepts through an adapted CBPR theoretical model with a focus on 4 dimensions—contexts, group dynamics, intervention, and outcomes—considered in developing and implementing a CBPR intervention project. We conclude with a case study of a behavioral intervention project in China to demonstrate how to apply CBPR principles in the context of global health and make several recommendations based on experiences gained from this and other projects.

    3. Page 299

      Global child health research plays a pivotal role in addressing inequities in children’s health and development worldwide. To achieve this goal, research must be based on sound scientific and ethical principles. This chapter focuses on ethics in child health research in low-, middle-, and high-income countries. It reflects on the key principles underlying ethical research in general and in global health research and child health research in particular. This is followed by a detailed discussion of 3 core principles underlying child health research: respect, benefit, and justice. Research with children poses important and universal ethical issues across world contexts, including establishing consent, protection from harm, privacy, and payment and gifts. Cultural, social, political, and economic factors that can interact to pose particular challenges with regard to these issues in different contexts, especially in low- and middle-income settings, are explored. As methodology and ethics are integrally linked, this chapter also examines the ways in which children have been included in health research studies: research on children, research with children, and research by children. This is followed by a brief discussion of ethical mechanisms that are in place to ensure that ethical standards are met and maintained in research on global child health. The chapter concludes with a discussion of the many positive changes in ethical research involving children in recent years. Emerging ethical challenges in the fields of genetics and genomics are highlighted.

    4. Page 321

      GHESKIO (Groupe Haitien d’Etude du Sarcome de Kaposi et des Infections Opportunistes/The Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections) Centers, founded in 1982, is one of the oldest institutions dedicated to the fight against HIV/AIDS. GHESKIO has 3 main objectives: patient care, training of medical personnel and community leaders, and operational research. GHESKIO efforts are focused on 4 of the most important diseases in Haiti: diarrheal diseases, HIV/AIDS, other sexually transmitted infections (STIs), and tuberculosis (TB). The emphasis is on the family because the diseases that the GHESKIO Centers are concerned with are likely to be spread in the family setting. From its inception, GHESKIO Centers have been affiliated with Cornell University Weill Cornell Medical College and the Haitian Ministry of Public Health and Population (MOPHP). GHESKIO is an official nongovernmental organization recognized by the Haitian government and working in close collaboration with the Haitian MOPHP, which has provided GHESKIO with facilities at the university hospital and at the National Institute Research Laboratory. GHESKIO is the country’s referral center and the Caribbean-leading institution for treatment and research in HIV/AIDS, STIs, TB, and diarrheal diseases.

      In the 36 years since its inception, the GHESKIO Centers have continued to evolve and grow despite the challenging sociopolitical and economic conditions of the country. Haiti is the poorest nation in the western hemisphere, with 80% of the population living under the poverty line and 54% in abject poverty.1–3 Haiti has the most significant HIV and TB epidemics outside of Africa. In addition, in the past 6 years, Haiti has weathered 3 of the most devastating natural catastrophes in recent times, including a magnitude 7.0 earthquake in 2010, the largest and deadliest cholera epidemic that same year, and a devastating category-5 hurricane, Matthew, in 2016.

      The GHESKIO model offers integrated preventive and curative services for HIV, TB, STIs, and diarrheal diseases in 2 campuses located in the north and south of Port-au-Prince. This approach has been expanded to include other notable diseases and services. All services are offered at each site to facilitate access to comprehensive care in a “one-stop shop” approach because the poor often cannot afford to travel to different health facilities for all their families’ needs. In addition to health services for HIV/AIDS, including the provision of antiretroviral therapy, treatment for STIs, TB treatment, psychological care, and reproductive health, support is provided with microcredit opportunities, primary and vocational school scholarships, and community outreach interventions that complete the global health model of GHESKIO. The story of GHESKIO is a model of success despite adversity, addressing significant public health problems and making a difference locally and internationally.

    5. Page 339

      Injuries are a leading cause of death and disability among children throughout the world. It is estimated that 735,500 children and teens younger than 20 years die from unintentional injuries annually. Although injuries are one of the most common causes of pediatric mortality globally, they do not affect all regions of the world equally. Low- and middle-income countries not only experience pediatric injuries at a much higher rate than high-income countries, but they also have greater total injury-related mortality and morbidity. An estimated 97% of all pediatric unintentional injury-related deaths occur in low-and middle-income countries.

      This chapter will describe the global public health burden and leading causes of unintentional injuries to children. We will also discuss the application of the public health approach and the principles of injury prevention to child injury. Best practices and case studies will be presented to highlight innovative research studies and evidence-based injury prevention strategies that have been implemented in low-, middle-, and high-income countries. The chapter closes with an overview of current research gaps and suggestions for advancing the field.

      This chapter will not discuss intentional injury specifically, which, in the editors’ assessment, deserves a detailed and comprehensive thesis— not achievable in a single chapter.

    6. Page 359

      There is ample evidence that child maltreatment (child abuse and neglect) is a prevalent problem, globally. Every 2 years since 1982, the International Society for the Prevention of Child Abuse and Neglect (ISPCAN) conducts a survey to assess the state of child maltreatment and child protection internationally. This chapter is excerpted and based on World Perspectives on Child Abuse, 11th Edition.1* Those wishing to read the full report, including detailed information on individual countries, can obtain a copy from ISPCAN at www.ispcan.org.

      It is naturally difficult to cover the entire world and to capture what is happening related to child maltreatment and child protection in many countries in any depth. Nevertheless, data from this survey offer a valuable snapshot of policies and practices pertaining to child maltreatment in different regions of the world and according to country income level.

      With members in more than 100 countries, ISPCAN has the capacity to identify knowledgeable professionals in the field of child maltreatment. ISPCAN initiated the current survey with respondents to past surveys. In addition, potential participants thought to be familiar with child protection in their countries were sought from ISPCAN membership. ISPCAN and executive council members were also asked to reach out to their networks, particularly in countries in which a respondent had not been identified. In addition to individual connections, ISPCAN works with national organizations in several countries as well as other international organizations. They too helped identify key informants to complete the survey. Repeated efforts were made to reach respondents in as many countries as possible.

      Of the 96 countries with identified respondents, 76% completed the survey. Of the 73 countries represented, 10 were from Africa, 14 from the Americas, 25 from Asia, and 23 from Europe; Oceania was represented by just Australia. Using designations of the World Bank, there was good representation of high- and middle-income countries (33 for each), but only 7 responses were from low-income countries. Caution is naturally needed when interpreting findings based on low numbers.

      The editor, together with an international advisory committee, developed the survey, building on prior iterations. Participants were invited to complete the survey, administered online using SurveyMonkey. Each respondent was e-mailed a link to the survey. They were also encouraged to seek input from colleagues when necessary, to help ensure the accuracy of the information. It is inherently difficult to know the many aspects of child protection in one’s country, especially when systems are not centralized and considerable variation may exist. It was beyond the scope of this project to check the accuracy of responses. These data, therefore, may not always accurately represent the complex picture or the variations within a country.

      The results of the survey help inform the status of maltreated children globally and likely system and programmatic interventions needed to ameliorate the status of children worldwide.

    7. Page 381

      There are challenges in establishing guidelines for care and in implementing evidence-based recommendations and guidelines in many countries. This is a reflection of nationalistic approaches to governance and, more specifically, national choices governing the social strategies that are deemed acceptable to decision-makers. These challenges are not limited to low- and middle-income countries; within the United States and other high-income countries, individual state and community governmental jurisdictions can be resistant to new evidence or to examples of successes that work in neighboring governmental units.1 But despite these nationalistic tendencies, efforts to share successful models for pediatric education have helped spread innovation and quality improvements in care to many countries over the past several decades. This chapter reviews some of the factors that made this spread possible, including the rapid growth and institutionalization of global health training in US residency programs; addresses the future development of competencies and ethical standards within the current framework of the UN Sustainable Development Goals; and provides a perspective on the role of US pediatric associations in setting and supporting the agenda for global child and adolescent health research, practice, and education.

    8. Page 391

      Hematology/oncology is a discipline that includes the study and treatment of diseases of the blood and tumors (benign and malignant) affecting the blood and body tissues. Because the diagnosis of blood diseases and cancer requires microscopic examination, traditionally, the specialty evolved as a part of the pathology discipline. As knowledge progressed, it became evident that many blood diseases and cancer have biochemical/ molecular underpinnings, and hematology/oncology came to be recognized as a laboratory medicine specialty. Herein lies the complexity of learning the biology of diseases included, as well in developing the strategies for management of each of the disorders encountered.

      In this chapter, a personal account augments the description of the status of chronic diseases represented in hematology/oncology in high-, medium-, and low-income countries. This approach allows for exploration of the essential elements of learning the diseases included. Also described are lessons learned of the strategies used in developing the resources needed to set up a high-level hematology/oncology program anywhere in the world. Many of the principles discussed apply to other specialty disease groups, notably immunology/rheumatoid diseases; inborn errors of metabolism, growth, and development; and congenital/ inherited disorders affecting virtually every organ in the body.

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