Masahiro J. Morikawa

Family medicine: Global health in practice

Masahiro J. Morikawa

For nearly 40 years, family medicine has been providing guiding principles in major global health programs. This article has two aims: (1) to review past major global health campaigns with a specific focus on the roles of family medicine to illustrate its relevance in global health, and (2) to address practical approaches to attain health, which nurture sustainability of local health resources and resilience of the community. Regardless of the differences in the goals of past global health campaigns, three key approaches have emerged as essential interventions in the field based on family medicine principles, the so-called six Cs. The key approaches are (1) to protect families, (2) to train health care providers, and (3) to empower people. Family medicine continues to be a powerful tool to improve people's health in our own communities and in global health practice.

Family medicine; primary care; global health

Family medicine is global health

Global health has been discussed as if it is practiced only by those who are trained in a special way. In reality, however, my daily practice in Cleveland and my experiences in global health projects have convinced me that they are not much different. In both settings, you have to be ready to deal with a whole range of patients'complaints that go beyond the scope of a narrowly defined field (comprehensiveness) in all of their stages of life (continuity) by mobilizing available resources (coordination of care). You deal with the most prevalent health problems of the target population (common diseases), covering beyond the realm of biomedical cure but within the psychosocial sphere (care) in such a way that the patients become able to help themselves where they live (community based). The principles of family medicine, designated as six Cs above, have been one of the guiding tools in global health practice for a long time. The following are some of the programs/initiatives that are developed clearly on those principles.

The Alma-Ata Declaration

The epoch-making Alma-Ata Declaration [1]in 1978 defines that health is for all people and has used primary health care as its principal tool to attain that goal. It emphasizes comprehensiveness, an approach that goes beyond"hospital-based" and "technology-based" care.It embraces community engagement in solving health problems with a belief that self-reliance and autonomy enable people to attain health and well-being. The meaning of primary health care in the Alma Ata Declaration is not simply a set of skills and knowledge to provide medical care,but also ones to help improve people's attitudes and motivation in attaining well-being through their participation in the process of change.

Child survival revolution

UNICEF's comprehensive GOBIFF (growth monitoring, oral rehydration salt, breastfeeding, immunization, female education, and fetal monitoring) program to boost mother and child health in the 1980s used the GOBI strategy [2]. It emphasizes a comprehensive approach, targeting children and women of all ages, that includes medical care, health promotion, and mobilization of resources in the community to tackle the most prevalent and pressing issues in mother and child health. As a result, childhood immunization coverage around the world has increased drastically.

The Integrated Management of Childhood Illness

The Integrated Management of Childhood Illness [3] campaign launched in 1988 by UNICEF and the WHO to deal better with common pediatric illnesses also aims to mobilize community-based resources. The strategy to disseminate knowledge and skills through community-based approaches for common diseases had a substantial impact on mortality of children younger than 5 years throughout the Millennium Development Goals (MDGs) period: there was a significant accelerating decline in mortality of children younger than 5 years after the launch of the MDGs initiative [4].

The Basic Package for Health

The World Bank and the WHO launched the Basic Package for Health [5] in the new millennium to rebuild the health system in postconflict communities. The concept of the Basic Package for Health was developed with a strong belief that solid primary care is the key to establishing a health care pyramid structure where effective health care services are delivered.The definition of primary care physicians is different in each country, from general internists to community physicians to family physicians, but the comprehensiveness of required skill set is not very different and the primary care providers are the foundation of the health system.

The Millennium Development Goals

In 2000, more than 140 countries ratified the MDGs as the development target for the next 15 years. This was the first major project to tackle poverty as a development topic.Poverty discourse in health brought a new dimension in public health, which is the topic of the social determinants of health [6] to address health in a broader and comprehensive context.

MDGs 3 and 4 are most relevant to family physicians and they are related to maternal and child health. The countdown reviews, however, revealed problems in achieving the MDGs as initially planned. Specifically, "comprehensiveness" of the service was not satisfactory because many MDG-related programs had been developed vertically without any integration among them.

Global health in practice

The above examples are only a few programs/initiatives in the past few decades, demonstrating how family medicine has contributed to the theoretical underpinning of major global health initiatives. To further strengthen strategies to attain health through primary care in communities both in emergencies and in development, three practical field interventions should be emphasized. These are (1) to protect families, (2) to train health care providers, and (3) to empower people.

Protect families

A young mother brought her 13-month-old boy to a makeshift clinic outside Prizren, Kosovo. It was December 1999,6 months after the end of the NATO airstrikes. The boy was active and playful that day. But the mother brought him to the clinic every day for 3 days for nonspecific symptoms other than vague abdominal pain, weakness, and subjective fever.I could not find anything seriously wrong with the boy in my examination. Then, it hit me that it was the mother who had complaints. I asked her about herself. Her husband was killed during the war immediately after the birth of the boy.More than 50 mothers and children were waiting in line in the examination room. There was no privacy, no chairs, no lights,not even heating, but they all waited quietly for their turn to be seen. Flurries outside were the sign of their first winter after the war. The electricity supply was erratic in the village,and the villagers still had to depend on UN supplies, including drinking water. The entire community along the Kosovo-Albania border was under stress, struggling with their daily lives, asking for mental or psychological help was extremely difficult.

The family is a building block of a community, and family physicians have focused on protecting the entire family. Often,reuniting a family is the first task that family physicians should engage in when they serve communities in postconflict regions or where there is massive migration. Family medicine is not only for those who already have families but is also for who are separated from the rest of the family or who trying to reunite with their family members.

Train health care providers

At a war surgery hospital in a jungle in southern Nepal where disarmed Maoist child soldiers and their families were accommodated, shrapnel extraction and stump revision for landmine wounds were daily routines. The makeshift field hospital in a tiny public health post was erratically supplied with electricity, with generator backup and tin roof with no alternating current, which made surgery a torturous ordeal.A large number of the child soldiers were suffering even more from insomnia and bodily pain after shrapnel removal.In the same hospital, newborn care was also routine because life goes on in any emergencies. The most seriously injured,such as spinal cord injury survivors, were accommodated in a dormitory, isolated from the rest of the group with neither physical therapy nor with the prospect of reintegration into the community. The entire group of these child ex-soldiers had to rely on a few ex-medics assigned to that task among them. They were the ones who used to run around the jungle with the soldiers and put the tourniquet on to those who were injured on the frontline. However, they had only limited training to care for the sick and the injured. When foreigners leave,these ex-medics continue to be the sole responders for any health emergencies.

In communities desperate for any kind of help, training health care providers is one of the first priorities. More importantly, identifying who are the actual care providers is the key task for outside helpers. As they regularly work with various levels of health care providers, family physicians are capable of identifying who are the most effective providers of care in their community and who should be trained. Any potential care providers can be trained: from physicians to professional nurses to auxiliary nurses to community health volunteers to mothers and other family members. The programs should capture local realities (common diseases) and priorities (community based) and be contextually appropriate.

Brain drain has been an issue in many low- and middleincome countries among qualified health care professionals.Some East African countries have been creative in dealing with the issue by developing so-called task shifting or task sharing, for which they train community health workers with advanced medical skills needed in their communities [7].

Empower people

In a remote village in northern Thailand, patients with hypertension and diabetes flooded into the district hospital. People with new cases of these illnesses diagnosed by village health workers were all referred to the district hospital, where the services are free or almost free because of governmental support, for initiation of treatment. However, there is no doubt that there will soon be a serious shortage of resources. There is rapid progression toward a Western lifestyle with fast food,smoking, and carbonated drinks [8]. Many peasants were waiting with bewildered faces not knowing what high blood pressure or diabetes means to them, sitting anxiously in a chaotic waiting room for many hours just to figure out what to do.As stated in the Alma-Ata Declaration, health and wellbeing will be attained through participation of the community.Empowerment and community mobilization are the strategies to facilitate this process. The Global Burden of Disease Study 2010 [9] demonstrated that the leading causes of deaths are now all related to preventable causes – alcohol use, smoking,and high blood pressure [10]. Sadly, approximately 80% of deaths related to noncommunicable disease are from low- and middle-income countries [11], yet most of those countries do not have enough health care resources to start treating noncommunicable diseases [12]. Prevention, spearheaded by education, mass campaigns, and individual counseling will be key strategies and they can only be achieved with active participation of the community.

Family medicine: The universal profession

The principles of family medicine (six Cs) demonstrate the ability of family physicians to appropriately assess individual and community problems, develop and implement interventions, and encourage participation in the process to enable people to attain health. Family physicians equipped with both community and bedside clinical skills are competent to work in any communities: low- or high-income countries, from communities torn by conflicts or natural disasters in dire need of help to affluent suburbs in highincome countries. The praxis of family medicine and its philosophy transcends borders. Family medicine is defined as one of the medical specialties in primary medical care. But as discussed above, when we have to deal with much boarder health issues and systems where the health care structure is compromised, family medicine can cover a much deeper and wider context of health, called primary health care. Primary health care is, as is defined in the Alma-Ata Declaration,a much more comprehensive concept – including medical care, prevention, and health promotion – than primary medical care. The path to attain this goal is through self-reliance by empowering people in the communities we serve. In this sense, I have come to believe that family medicine is a social movement in progress to improve people's health locally and globally.

Conflict of interest

The author declares no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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CORRESPONDING AUTHOR:Masahiro J. Morikawa Family Medicine and Community Health, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106-5036, USA

E-mail: mjmkobe@gmail.com

14 July 2015;

Accepted 12 August 2015