I still remember being on my way to a shift as a freshly minted EM resident, green to the world of EM with medical school and a master’s in global health behind me, but driving the journey ahead. I found myself en route with a senior colleague who had some Médecins Sans Frontières (MSF) experience under their belt. Eager to learn about practicing global emergency medicine, I was told “yeah… it’s more of a single person’s game.”

I was well prepared for this, as I would continue to hear advice from trusted attendings that low-resource setting work was a young person’s game, not compatible with marriage, or almost certainly a hard stop with kids. Nonetheless, with a child and partner, as I pursued a global health EM fellowship at the end of my EM residency at the University of Toronto, and after spending a month in Addis Ababa, and months in Northern Ontario, Canada, I can assure you that this is not true.

What is true for anyone pursuing Global Health is that it is a team effort – and I’m not just speaking about family. Of course, it’s important that your partner and dependents (older or younger, family or friends) are on board, but having a supportive ED and training program is crucial to success. I’ll come back to this in a bit.

We often talk about sustainability in global health practices as it is imperative to help create solutions with longevity and not leave a community or population worse off from the initiation of a partnership. However, something that is not touched upon as frequently is sustainability of global health practicing individuals. Over the years, I have spoken to a number of people who engaged in global health work as young professionals or trainees (MSF, relief work, public health, medical education), but as they progressed in their career, age, and life stages, felt that it was not feasible for a number of reasons.I hope this post will encourage you to continuously reevaluate their definition of “global health work”. When considering the concept of bridging access to patients who might have barriers to health opportunities via geography or other social determinants, the truth is, our colleagues in the North have been struggling to keep their EDs open for decades.

While my time teaching trauma and EM in Addis Ababa, Ethiopia was phenomenal – and a valuable experience given the almost decade long involvement I had with the Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) – I also recognize the impact my time in Northern Ontario had. I have noticed that even with the best intentions, people are consistently more interested in the work I was doing internationally versus in our own province. I want to share a bit about the amazing work our colleagues are doing to serve Northern communities.

The majority of the EM physicians at the particular hospital I worked at trained in family medicine and provide holistic care. It was not uncommon to chat with physicians who transitioned from a busy clinic, to an ED shift, before they started their week as hospitalist. It can not be overstated how hard they work  and how much they know about their patients and community. But due to the short supply of physicians, they are often relying on a small cohort to fill ED shifts when volumes go up and availability decreases. This is when they rely on regular locums and southern EM physicians to help them out. Reliable assistance helps alleviate shortages and overburdened schedules, as well as allow local physicians to have career longevity.

Regarding global equity, the nearest pediatric hospital, trauma centre, and several surgical specialties are hours away. Here are a few cases I managed during my time in rural Canada, while being a solo-coverage provider with phone backup available:

  • 10F, with developmental delay post meningitis as a newborn, presenting with Ludwig’s angina and peripherally shutdown requiring IV access, intubation, and transfer
  • 40M, blunt MVC rollover self-extricated with several orthopedic injuries including a fracture dislocation of his hip requiring reduction and transfer
  • 44F, suspected sexual assault and trauma with multiple lung contusions and large SDH with midline shift requiring intubation, ICP management, vasopressors, and transfer
  • 20 day old neonate, requiring congenital cardiac screening after a query cyanotic episode and follow-up to avoid transfer
  • 22F, with supraglottic foreign body sensation requiring an awake laryngoscopy (no NP scopes available) to evaluate for removal to avoid an unnecessary transfer
  • 62M, with traumatic de-gloving and distal phalanx fractures, requiring a revision amputation and weekend follow-up to bridge until he could be seen by plastics

To illustrate a similarity in access impacting level of care, here are a handful of cases from a shorter time period at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia:

  • 30F patient who collapsed on the way to the ER, pseudo-PEA with identified massive PE and proximal DVT on PoCUS but no access to thrombolytics (consideration of black market access but would not be timely)
  • Several pediatric patients in renal failure and heart failure from untreated strep infections
  • 20F patient with GBS, AMAN variant, who couldn’t afford IVIG so went home and returned with worsened paralysis

Some of these cases are challenging enough to make seasoned EM physicians sweat, even in a well-resourced setting. Furthermore, as far as global health goes, the many of the patients in Northern rural communities are indigenous, a historically marginalized population. It is indisputably global health work to serve a population and community that lacks the same access to resources as more urban regions in Canada. With that in mind, and with my own experiences, I have reflected on some of the reasons I have been told it would be difficult to practice Global Health longitudinally (usually regarding the considerations of international work) and how that doesn’t apply in our own low resource settings.

  • Concerns around travel insurance and medical care for dependents
    • Northern or rural work will usually be in your own province
  • Opportunity cost
    • You will likely be compensated for your work, via payment or residency
  • Sustainable practices
    • There are definite ways to engage in longitudinal partnerships (see below)
  • Losing “local” skills (e.g. interpreting standard obtainable ED investigations)
    • These are skills that will still be utilized in your northern work
  • Time off local requirements
    • Communities will often work with you to arrange shorter commitments
  • Time preparing for international departure
    • Visas and vaccines are usually not required, and your designations are likely streamlined as a current practicing physician in your province/country
  • Safety
    • Unlike relief work, your northern work will usually not be in war-stricken or disaster scenarios (unless specifically sought out)

At the end of the day, Global Health work takes many shapes and forms as long as the communities and populations are truly benefiting from the assistance provided. International work remains a fundamental part of building global equity in EM, and collaborations between countries can strengthen bidirectional partnerships. TAAAC-EM operates on longitudinal relationships, respect for local practices, and engagement of local partners. However, this can often be emulated in your own country (as most readers likely know) without the capacity to engage in Global Health work feeling like an all or none principle. Those same foundational pillars of TAAAC-EM guided me during my time in rural Northern Ontario. We collaborated to make a trauma checklist and comprehensive management of trauma patients pending transfer. With this project and education work in mind, they helped move shifts around to accommodate my return. They even tracked down a playpen and accommodation near the hospital for my son to sleep in and genuinely made things easy for my family (along with countless offers for playdates). Global Health work can be hard, and with EM being a specialty fraught with burnout, the combination can prove difficult. Just as we try to eliminate barriers to accessing health for patients, it’s important we preserve the equity-seeking healthcare workers and highlight the opportunities to help underserved communities. I rarely had a shift in rural Northern Ontario where a patient did not thank me for my time or coming to help keep the hospital open. As a family man, I still feel able to do global health work longitudinally, and it is the partnership with the rural Northern Ontario hospital that allowed this to happen.

Edited by Hiren Patel, Matt Douglas-Vail, Navpreet Sahsi and Anton Helman

Drs. Sithamparapillai, Patel, Sahsi and Helman have no conflicts of interest to declare