2. Objectives
To recognize the importance of global health
initiatives in pediatrics
To understand the universality of infant and child
health and safety issues
To recognize some of the important differences
and similarities in healthcare systems in a
developing country
To develop increased cultural competence –
increasing numbers of international travel,
adoptions, and medical tourism
3. Physicians for Peace
Founded by Dr. Charles Horton in 1989
Mission: To develop sustainable programs in the
developing world based on the belief that health care
can best be improved by training health professionals
in that country, who then can continue to heal
hundreds to thousands of people there
Programs designed by communicating with
physicians indigent to the area with regards to
educational activities they feel will most benefit their
community
4. Physicians for Peace
NALS/PALS/nursing education
Nagpur, Maharashtra, India
In collaboration with Dr. Satish
Deopujari, pediatrician and co-
founder of Child’s Hospital of
Central India
Our mission consisted of:
Dr. Ed Karotkin,
Neonatologist
Ms. Karen Horton, Neonatal
Nurse Educator
Dr. Sheetal Ajmani, PGY-3
5. Physicians for Peace
Specific Programs Completed:
Nursing education to 125
nurses in Nagpur, India and
60 nurses at Sawangee
Medical College
NALS reviewed with 15
pediatric residents at
Sawangee Medical College
PALS workshop with 40
practicing pediatricians in
Nagpur
Neonatology topic-specific
updates given to 20
practicing pediatricians in
Nagpur, as well as to 15
pediatric residents at
Sawangee Medical College
14. Healthcare System in India
Subcenter: staffed by 1
female worker and 1
male worker and covers
a population of
3000-5000
Primary Health Center:
staffed by 1-2 physicians,
and 2 or more ancillary
healthcare workers and
serves a population of
30,000
Each PHC oversees
6-8 SCs
Each CHC serves 3-4
PHC’s
15. Healthcare System in India
Hospitals
Government vs. Private (Nursing Homes)
No good public medical transportation system
At private hospitals, families must be actively involved
in all decision-making, since they must be able to
directly pay for care (including all lab tests, radiology,
and treatment plans)
1 relative must stay at bedside at all times
If a new medication is needed, the family is given the
prescription to be filled at the pharmacy and bring it
back to be administered
No family members allowed in ICU’s
16. Healthcare System in India
Infection control in ICU’s (hats, gowns, shoe covers)
No incubators in NICU; only radiant warmers (and
use plastic wrap if needed)
No consistent temperature control on the warmers in
the NICU
Role of nurses is minimal
Blood bank
PALS
No manometers on BVM
Broselow tape
Workshops – airway opening maneuvers
17. Antenatal Care in India
Family planning education is lacking
Contraception: sterilization accounts for 75%
of all contraceptive use
60% of women child-bearing age never heard
of AIDS (2003)
30,000 HIV+ infants born/year (by conservative
estimates)
In 2007, 159 cases of HIV were diagnosed in
children under 13yo in the U.S.
18. Antenatal Care in India
Since pregnancy is ‘natural,’ use of prenatal
services is considered unnecessary by many
Government hospitals provide financial
incentive to mothers to deliver in hospital,
including transportation
65% of deliveries are at-home
2% of families sought medical care for mother
or child within the first 2 days
17% sought medical care within 2 months of
delivery
19. Child and Infant Mortality
India contributes to 25% of the 10 million
deaths under 5 years of age in the world
Neonatal mortality rates (per 1000 live births)
U.S. 4:1000
India 39:1000
20. Child and Infant Mortality:
Distribution of Causes of Death <5yo
(2000)
India U.S.
Neonatal 45.2 56.9
HIV/AIDS 0.7 0.1
Diarrhea 20.3 0.1
Measles 3.7 0
Malaria 0.9 0
Pneumonia 18.5 1.3
Injuries 2.2 10.3
Other 8.5 31.3
22. Healthcare System Comparison
Physician to 10,000 population ratios
U.S. 26:10,000
India 6:10,000
In India, 74% of physicians live in urban
areas, where only 28% of population resides
23. Himalayan Health
Exchange
Mission: To provide medical and
dental care to the underserved
people living in remote regions
of the Indian and Nepal
Himalayas
NGO based out of Atlanta, GA
Founded by Ravi Singh in 1996
Eight expeditions/year
comprised of physicians,
dentists, nurses, pharmacists,
and medical students
24. Dharamsala Expedition
April 2008
37 Health professionals: 7
physicians, 29 medical students, 1
RN
Also, 1 local pharmacist, 1-2 local
physicians/each clinic site, staff of
cooks, drivers, and translators
Provided care at 7 rural villages, and
2 monasteries
About 2700 patients seen; ¼ of
which were pediatric
My role: Providing medical care at
the attending level in the Pediatric
medical tent. Supervision of 5-7
medical students/day in the
Pediatrics tent
30. Scabies
Species: Mite Sarcoptes scabiei; females are fertilized at skin
surface, then burrow into the epidermis, traveling 2mm each day
while laying a total of 10-12 eggs, female dies in 1-2months
Epidemiology: crowded areas, in colder and more humid
conditions (long survival on fomites)
Transmission: person to person; direct contact; very contagious
Clinical features: itching due to type IV delayed hypersensitivity
reaction, worse at night and out of proportion to visible
dermatologic manifestations; secondary staph infections
common
31. Scabies
Diagnosis: History and
physical exam; family
members typically affected;
can microscopically
visualize mites from skin
scraping, but not necessary
for diagnosis
32. Scabies
Treatment:
-First line: Permethrin 5% cream (safe in
infants; cotton mittens to prevent toxicity);
Oral Ivermectin
-Alternative Topicals: Benzyl Benzoate,
Lindane, Malathion, Sulfur in Petrolatum
-Treat all household and close contacts
-Treat secondary reactions: anti-pruritics;
secondary staph infections
34. Tinea capitis
Gray patch tinea capitis: Microsporum Canis (bright green
flourescence under Wood’s lamp); erythematous patches with
scale; may develop into kerion (boggy, tender nodules with
exudate) and/or secondary staph infection
Black dot tinea capitis: seen more in the U.S.; Trichophyton
tonsurans; erythematous patches with “black dots” from hairs
breaking off in affected areas
Treatment: Griseofulvin is the primary treatment choice
(20-25mg/kg/day for 6 weeks); Other treatment options include
terbinafine, itraconazole, fluconazole
35. Tinea corporis
Circular patch with central
clearing and raised,
erythematous border
Treatment:
-Local – topicals including
miconazole, ketoconazole,
clotrimazole
-Systemic – for widespread
infection; griseofulvin,
terbinafine, itraconazole,
fluconazole
37. Pinworms
Enterobius vermicularis
Humans are the only host
Most commonly affects school-age children
Present with itchy butt, worse at night
Female pinworms crawl out of the anus to deposit eggs
at night
Spread by contact/fomites
Scotch tape test – eggs will be visualized on a single
specimen 50% of the time; 90% if have 3 samples
Treatment
Albendazole as single dose; or, mebendazole once
and again 2 weeks later
42. Summary
Participation in international health electives is an
invaluable experience:
PFP: Develop academic and professional networks
with international community of healthcare
professionals
HHE: Gain experience practicing medicine with
limited resources, and gain insight to different
perspectives and opportunities for healthcare
Welcome Shruti Deapujari to CHKD
